‘It became pretty clear early that we weren’t ready’
Health-care leaders say they sounded the alarm to the province as early as January about the vulnerability of nursing homes to COVID-19. As the outbreak began, they say that sector was overlooked until the virus struck long-term-care facilities
Vicki McKenna came to the Ministry of Health’s offices with a warning.
It was Jan. 20, and McKenna, president of the Ontario Nurses’ Association, and the organization’s CEO were meeting with Health Minister Christine Elliott.
The nurses, troubled by the unspooling news of how COVID-19 had besieged the health-care system in Wuhan and was now popping up outside of China, told the government that years of understaffing had left Ontario’s nursing homes just as vulnerable.
“When we started to see what was happening in other jurisdictions, the flags going up, we asked: ‘What are we doing about this? Are you acting on this?’ ” McKenna said.
The minister, she recalls, listened to their concerns and said the province was monitoring the situation.
Five days after that meeting, the first case of COVID-19 was identified in Ontario.
Over the next two months, unions for front-line staff, seniors’ advocates and long-term-care experts say they continued to sound the alarm in conversations with both the Ministry of Health and Ministry of Long-Term Care.
They say the long-term-care sector was overlooked as strained acute care resources were shored up in response to dire international reports of overwhelmed intensive care units.
Meanwhile, the well-known cracks in Ontario’s nursing home system were allowed to become deadly sinkholes, according to experts and frontline staff, as well as allegations made in court.
One hundred days after the province’s first COVID-19 case, the virus has killed 1,300 people. Seventy-five per cent of them were nursing home residents. If not for Ontario’s flat-footed response in its nursing homes, some of those deaths might have been averted.
“They listened but there was no action,” McKenna said. “Until there were positive cases starting to percolate in long-term care, that’s when the light went on … and the focus turned to long-term care.”
“They listened but there was no action.”
Vicki McKenna, president, Ontario Nurses’ Association
In late March, as deaths inside nursing homes started to surge, Ford and his government vowed again and again to fortify the porous line of defence meant to protect Ontario’s most vulnerable from a virus that has them, more than anyone, in its crosshairs.
Provincial and federal officials lamented how the virus’s devastation of frail seniors was “unprecedented,” and the country simply did not have a “playbook” for handling COVID-19 in nursing homes.
But there were several playbooks — federal and provincial pandemic plans, post-SARS reports and infection prevention and control guidelines — all painstakingly developed in preparation for the inevitable next pandemic.
They predicted that elderly people, due to declining immune systems and multiple health conditions, would be among the hardest hit.
And once inside a home, the virus could spread fast. Higher transmission risk factors listed in the 2011 document “Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector” include shared rooms, shared bathrooms, high nurse-to-patient ratios, lack of space to isolate infected residents, an inability to have different staff for infected and uninfected residents, and the inability to keep a physical distance of two metres or more between residents.
Many, if not all, of these factors were present at Ontario long-term-care homes, especially in older facilities where up to four residents share a room.
Given the risk for rapid spread and the high-risk population, the stated goal of the plan for long-term care was “to keep the facility (or major areas of the facility) completely free of influenza.”
“We knew exactly what was going to happen … We saw it in Asia. We saw it, particularly in seniors in congregate care settings, in Italy and Spain and then France,” said Laura Tamblyn Watts, CEO of CanAge, a national seniors advocacy organization.
Tamblyn Watts said she has been part of a chorus of long-term-care experts and front-line health care workers that for weeks had been calling for more aggressive, meaningful government action to help halt the virus’s wildfire spread through nursing homes.
“We knew what was needed,” she continued. “The problem was the Ontario government didn’t do it.”
In an emailed statement, spokespersons for the Ministry of Health and Ministry of Long-Term Care said the focus of the province “has been on ensuring that these homes have the resources they need, including filling any urgent gaps.”
The province’s increasingly stringent measures “are building an iron ring around long-term-care homes so that we can protect our province’s most vulnerable,” the statement said.
The COVID-19 virus is especially dangerous in part because of how it can sweep through society via “silent spreaders” who display no symptoms, rendering normal screening measures focused on temperatures and symptoms far less useful.
While the prevalence of asymptomatic transmission was initially unclear, experts say that once it was suspected, Ontario should have moved beyond symptom screening and close-contact testing to widespread testing in all longterm-care homes even without an outbreak.
“With regards to what could have been done … what we’re doing now, but doing it a month ago, would have prevented a lot of this,” said Dr. David Fisman, an epidemiologist at the University of Toronto’s Dalla Lana School of Public Health.
Jan. 25: Ontario’s first COVID-19 case In a memo on Jan. 27, chief medical officer Dr. David Williams said the two initial cases, a married couple who had returned from Wuhan, were not unexpected. The risk to Ontarians remained low, but more cases were expected to arise among travellers.
At the start of February, the Ministry of Health issued guidelines to long-termcare homes requesting passive screening of visitors, staff and volunteers, and active screening of residents.
Signs instructed people to self-identify if they had travelled to China or had symptoms like fever or acute respiratory illness. Residents were to be monitored for fevers, coughs or trouble breathing.
It was only after the virus had ripped through some long-term-care homes that they were able to move residents into single rooms because COVID-19 had killed the previous occupant, some front-line staff said. Mount Sinai geriatrician Dr. Nathan Stall said the virus is estimated to kill about a third of infected long-term-care home residents.
The nursing home sector was in crisis long before COVID-19, said Pat Armstrong, a sociology professor at York University and lead author of the Canadian Centre for Policy Alternatives’ April 2020 report “Reimagining Longterm Residential Care in the COVID-19 Crisis.”
Long-standing staffing shortages stemmed from low pay and a reluctance to provide full-time hours and benefits. Volunteers and family members have tried to fill the gaps.
Personal support workers, primarily racialized and immigrant women who do the challenging work of bathing, changing and feeding residents, are forced to work at multiple homes to get enough hours.
The sector’s increased reliance on part-time workers reduced employees’ awareness of infection protocols, the 2003 Naylor report on the SARS outbreak found. And the hourly pay and lack of sick leave or benefits meant there was an incentive to work while ill.
Evidence from the battle against COVID-19 overseas emerged early.
By mid-February, China’s Centre for Disease Control released data showing the fatality rate for COVID patients 80 years and older was 14.8 per cent, more than six times the death rate for the population as a whole. By early March, researchers in Italy found that, of 105 deaths, the average age was 81.
Feb. 28: Life Care Centre outbreak Then came what Tom Frieden, former director of the U.S. Centers for Disease Control, called a “sentinel event” for North American nursing homes — the outbreak at Life Care Center in Kirkland, Wash.
The first positive case was confirmed Feb. 28. Just over a week later, 81 residents were infected and 22 were dead. On March 8 — the same day as the first death in Canada, at the Lynn Valley nursing home in Vancouver — Frieden pointed to the Life Care Center outbreak and called nursing homes “ground zero” for COVID-19. He called for visits to be restricted and measures, such as paid leave, to ensure sick staff stay home.
It would be five days before Ontario’s chief medical officer of health advised nursing homes here to bar all but essential visitors.
With health officials focused on preparing hospitals for an onslaught of COVID patients that could overwhelm intensive care units, the province urged that certain COVID-negative patients be transferred out of hospitals and into long-term care, where they would be isolated for two weeks.
“Our acute care system was inoculated, as it were, by SARS. And that’s been really awesome,” said Colin Furness, an infection control epidemiologist at the University of Toronto. But long-term care was not.
“It became pretty clear early that we weren’t ready,” said Sharleen Stewart, the president of the Service Employees International Union Healthcare, whose members work in nursing and retirement homes.
In meetings with officials from the ministries of health and long-term care through early March, “a lot of us brought up SARS and it kind of just went without response. We were asking the employers and the government particularly at that time, ‘What was the (personal protective equipment) situation?’ They said we had an adequate supply, which was not what we were hearing on the front lines,” she said.
Protective gear was already in short supply at the end of January, with some homes reporting they were unable to procure PPE from their usual supplier.
The province was not taking the risk to long-term-care homes seriously enough, she said.
“The more I watched this and the more I looked back over the weeks and months of how this was handled, I think this government chose who lives and dies. I really do,” said Stewart, speaking the day after a memorial for a personal support worker who died from COVID-19.
“We knew exactly what was going to happen ... We saw it in Asia. We saw it … in Italy and Spain and then France.” LAURA TAMBLYN WATTS SENIORS ADVOCATE
March 8: First death in a long-term-care home in Canada The day after the death of a resident at the Lynn Valley care home in North Vancouver, Ontario’s Ministry of LongTerm Care sent a memo instructing homes to “actively screen” all visitors and residents, and advised staff to monitor for symptoms.
In Ontario, the focus remained on travel-related cases, as Williams, the chief medical officer of health, assured “the virus is not circulating locally.”
On March 16, all returning travellers were told to self-isolate with the exception of health-care and essential workers.
Two days later, health workers were included but, Stewart said, some employers were telling staff to get back to work if they weren’t showing symptoms.
“And honestly, that’s when my hair caught fire. It’s like, I’m in the same world that they’re in. And it was already talked about that this was spread to asymptomatic people. So once you have the symptoms, it’s too late,” she said.
By then, cases of community spread were beginning to emerge. March 9 is when the first residents at Pinecrest nursing home in Bobcaygeon, Ont., likely became infected, according to a letter written by a cardiologist in nearby Lindsay. In the ensuing weeks, at least 29 residents of the 65-bed home would die from the outbreak.
Mississauga truck driver Terence Van Dyke was glued to the news, listening intently for anything about the home where just a month earlier he had moved his father — Eatonville Care Centre in Etobicoke.
“They weren’t on the news so I assumed they were doing things right,” Van Dyke said.
His father, William, had been living at a retirement home in Simcoe. Worried that his father’s condition was worsening, and that if he didn’t pounce on the available bed his father would lose his spot in Ontario’s long queue for longterm care, Van Dyke moved him to Eatonville. As he helped his dad settle in to a cramped, shared third-floor room, Van Dyke’s heart sank.
“When I left that day, I cried. I felt like I had taken him from the Hilton and dropped him at a Ramada Inn,” he said.
The website for Eatonville, a for-profit home owned by Rykka Care Centres, offers only shared rooms, some with as many as four beds. These ward rooms, common in older homes, are tinderboxes for the transmission of viruses, experts say. “There is simply no way to institute appropriate infection control,” Tamblyn Watts said.
Inside Eatonville, sick residents were not properly separated from the healthy, while staff were made to wear the same soiled protective gear while caring for all residents, according to allegations filed in court by unions representing frontline health-care workers.
A respiratory virus outbreak was declared on units 2, 4 and 5 on March 16, according to submissions by the Ontario Nurses’ Association.
“The symptoms associated with the outbreak were consistent with a diagnosis of COVID-19. Residents on Unit 3 also became symptomatic, but were permitted to move about freely,” the ONA alleged.
“Staff were given two masks at the start of each shift, told to only put them on if caring for a patient with COVID-19, and told to put the mask in their pocket at other times so that they were not walking the halls looking ‘suspicious,’ ” the nurses union alleges. At another Rykka-owned nursing home, staff used privacy curtains to “mitigate the spread of COVID-19” in shared rooms.
The ONA took Rykka to court, where a judge ordered the company to make sure sick and healthy residents were properly segregated and staff did not cross between the groups, and that nurses had access to high-grade N95 face masks if they deem it appropriate. The judgment applies to three Rykka homes, including Eatonville, where COVID outbreaks have claimed the lives of at least 83 residents.
In a separate complaint filed on behalf of two Eatonville employees who caught COVID-19, the Service Employees International Union alleged to the Ontario Labour Relations Board that staff were not being told who was infected.
“Staff are being forced to ‘guess’ who is infected based on who is in isolation and who has a ‘STOP’ sign on their room doors,” the complaint alleges. “It seems that Eatonville has been very lax with their preventative measures around COVID-19 and has disregarded many of the prevention protocols that should have been put in place right away when the pandemic started.”
Evelyn MacDonald, the executive director of Eatonville, said in a statement that the home is using “up-to-date guidelines from Public Health and the chief medical officer of health on infection control best practices, personal protective equipment standards, and testing guidelines” to mitigate the spread of COVID-19 inside the home.
In an affidavit filed in court, MacDonald said nurses have had access to surgical masks and other protective equipment since the outbreak began in midMarch, and have kept staff and residents’ families informed throughout the crisis.
“During these challenging times, we continue our efforts to protect our residents and staff by leveraging the best policies and practices available,” she told the Star.
March 17: State of emergency On March 22, five days after Premier Ford declared a state of emergency shuttering schools, libraries and sit-down restaurants, Williams’s office issued a directive barring residents from leaving nursing homes to see family or friends, and stipulating that visits to homes had to be conducted with social distancing. The directive also advised that wherever possible, homes would work with staff to limit the number of facilities they work at “to minimize risk of patients to exposure to COVID-19.”
This was only a recommendation, and would not become a mandatory policy until a month later.
“This was one of the ways that SARS was getting between facilities,” said Dr. Samir Sinha, head of geriatrics at Mount Sinai and the University Health Network. “So what did the SARS Commission say back in 2004? We have to end that practice. But we never did — because it would mean we had to fund the system better.”
Staff members working in multiple facilities contributed to the fatal outbreak at a Washington nursing home, a March 18 report by the U.S. Centers for Disease Control concluded.
On March 27 in British Columbia, where officials believe the virus arrived at the Lynn Valley nursing home through a care worker with multiple employers, the provincial health officer, Dr. Bonnie Henry, made an order limiting movement of staff at long-termcare facilities. The move was estimated to cost $10 million a month.
Ontario did not order a halt to staff movement between homes for another two and a half weeks, and the ban would take another week to come into force.
Henry’s actions may have charted a radically different course for B.C.’s nursing homes compared to those in Ontario.
“They weren’t doing any better than we were doing in Ontario” in terms of their systemic issues, said Sinha. “Ontario didn’t act as decisively as B.C.”
In an emailed statement, spokespersons for the Ontario ministries of health and long-term care said the two provinces have “very different” longterm-care sectors. On March 25, Ontario provided $243 million in emergency funding “to support homes to rapidly hire and retain nurses, personal support workers and other front-line staff, as well as to create additional emergency capacity to support the isolating and cohorting of residents and staff as needed.”
The same day Henry took aggressive action, Sinha sent an email with a dire warning to the office of Ontario’s minister of seniors.
“I fear that right now we are not getting ahead of this in Ontario the way we need to,” reads the email, a copy of which was obtained by the Star.
Sinha warned that the latest evidence showed symptom-based screening might not capture COVID-positive carriers who are asymptomatic or not yet showing symptoms. “MY BOTTOM LINE — 50% of the residents who tested positive were ASYMPTOMATIC or PRE-SYMPTOMATIC. Once there is a case, everyone in a unit/home should be tested. All staff should be wearing PPE,” the letter said.
On March 27 the province continued to reject residence-wide testing, even in homes where there were outbreaks. At a press conference that same day, associate chief medical officer of health Dr. Barbara Yaffe said, “We don’t want to use up the limited lab resources to test everybody when we already know what the cause of the outbreak is.”
Health officials changed their tone on April 15. Part of the “COVID-19 Action Plan” would now include “aggressive testing” of all residents in homes with outbreaks, with plans to expand testing for long-term-care residents and staff.
In the days following health officials’ dismissal of residence-wide testing on March 27, until their approach changed on April 15, internal government data shows COVID deaths in nursing homes grew from 11 to 257 — an average daily jump in deaths of 21 per cent.
Even though Ontario did not have the capacity for widespread testing at first, the strategy should have shifted sooner to test widely in long-term-care homes in recognition of evidence of how fast and easily the virus spreads, epidemiologist Furness said.
The virus was still running rampant through Eatonville. Among those soon to be infected: William Vonnell Van Dyke.
His son, Terence, woke up around 9 a.m. on April 11 and saw he had 19 missed calls from a number he did not recognize. It was St. Joseph’s Hospital, where his father was now on oxygen.
Within three hours, his 85-year-old father was dead.
He said he only found out that his father had tested positive for COVID-19 from the funeral home director. It was days more before he heard from anyone at Eatonville.
Although the home was kind to his father, Van Dyke questions why he was left in the dark and why his father was not tested sooner, especially because he had developed a fever after returning from a hospital, where he had surgery, in mid-March.
As the death count continued to climb at Eatonville and other long-term-care homes, Van Dyke said he spiralled further into grief.
“I felt guilty because I put him there,” Van Dyke said, sobbing. “All I could do … was look at a photo of my father and apologize.”
April 15: ‘Fortifying the iron ring’ “When they look back on this, when the history books are written, we will be judged on how we looked out for each other. But even more importantly we will be judged on who we looked after,” said Premier Doug Ford in a sombre, emotional press conference announcing the province’s plan to “throw everything we’ve got” at long-term-care homes, including hospital “SWAT teams” and more testing.
“We will fortify the iron ring of protection around our long-term-care residents and those who care for them,” Ford said.
Toronto epidemiologist Fisman says the virus’s full impact on nursing homes cannot yet be known because there has not been enough testing. There is also limited post-mortem testing, which means the death toll from the virus among seniors is likely undercounted.
Although the widespread devastation inside Ontario’s nursing homes has exposed the repercussions of years of neglect and underfunding of long-term care, seniors advocate Tamblyn Watts said she hopes it has also shone a spotlight on what needs to be fixed.
“If one good thing comes out of this, it will be a rethinking of how we provide seniors care and care for other vulnerable populations,” she said.
“I felt guilty because I put him there. All I could do … was look at a photo of my father and apologize.” TERENCE VAN DYKE WHOSE FATHER, WILLIAM (ABOVE), DIED DURING THE OUTBREAK AT EATONVILLE CARE CENTRE