Ontario’s tragedy in long term care homes and retirement homes

Dear All,

Today, Good Friday, April 10, focuses on long term care. I chose this as my report’s focus as their residents are most affected by COVID-19 – in their isolation from loved ones and in the devastating fatalities we as a society have experienced. For the families and friends of residents in nursing homes and retirement homes and especially those who have lost loved ones: our hearts are with you at this difficult time. We told you to stop visiting your loved ones so we could keep them safe. And, so far, we have failed you. For this, as a nurse and a health system leader: I apologize.

To residents in nursing homes and retirement homes, to their families and friends, and to all staff working so very hard: Know that RNAO will continue to pressure – without any stopping --that all necessary measures to protect residents in nursing homes and retirement homes be fully and immediately implemented. As we protect them, we also need to protect the staff, as the safety of one is the safety of the other.

We know, that even when all measures will be put in place – and they must – we will still have lives lost – but many will be saved, and families who were once told to stay away will be once again be able to reunite and embrace.

This blog is testament to the profound sadness at what’s happening and RNAO’s unwavering efforts to push for urgent interventions to save lives, help with the existing outbreaks and prevent new ones. We call on governments at all levels and their health officials – in the strongest possible terms – to act immediately and comprehensively.

In todays’s report, we also describe the direct actions that RNAO is taking and for which we have full control, to support families and staff in nursing homes and retirement homes.

RNAO policy corner – Ontario’s tragedy in long term care homes and retirement homes

A tragedy of major proportions has been unfolding in front of our eyes in nursing homes and residential care in Ontario; the response so far has been slow, partial and ineffective. How many deaths are required until we start taking this horrific situation with the urgency, rigour and resources it requires? Words and promises do not suffice, what is needed – immediately – is action.  

The outbreaks are spreading like fire in dry bush. We hear anecdotal evidence of terrible situations in some of the institutions. Many nursing homes are depleted of staff to start with, and now are facing dire lack of staff, many of which are sick or in isolation or unable to work, and we hear some reports of residents who are virtually abandoned in their rooms. Most nursing homes and retirement homes are doing heroic efforts to attend to their residents and provide dignified care under conditions they would have never imagined before and without the basic tools required, such as adequate staffing and PPE.

For the families, the situation is desperate. The homes and residences, rightly so, have limited visits so they are physically unable to visit their loved ones. They are also urged to have very difficult conversations given the clear message that treating the elderly and frail in hospitals may not be in their best interest. Are the LTC institutions set up to facilitate the passing away of so many residents, within the home, with dignity and the palliative care they deserve, and without the presence of family members? What will be the lasting trauma for families, staff and administrators who have to live through this nightmare?

The latest information we have is that there are over a 100 nursing homes in outbreaks and 40 or more retirement homes, across Ontario. Some of the information shows devastating scenarios, such as the Seven Oaks senior home in Toronto, with at least 16 deaths, 45 confirmed cases and 56 probable cases of COVID-19 among 249 residents. There were also 13 confirmed cases among staff members.

That the LTC sector is not prepared for this crisis is an understatement, and something all governments in Ontario have known for many years. The sector has been severely under-resourced, under-staffed and under-priorized for decades. RNAO has repeatedly called for changing the provincial government formula for funding of nursing homes and for changing the staffing levels and mix. The changes so far, prior to the COVID-19 pandemic, have been minimal.

Indeed, these are the reasons why the sector was in a shambles during the 2003 SARS epidemic. RNAO was already saying then that the SARS outbreak was exacerbated by a “nursing workforce that battles with dangerously low staffing levels, high workloads, and an over-reliance on part-time, casual and agency staff.” Sadly, the only area where staffing has improved, in nursing, is that now we have a higher proportion of the workforce employed full-time. Nothing else has changed in any material way since 2003.

In RNAO’s report Mind the Safety Gap – released in 2016 and well known to past and current to past and current governments in Ontario – RNAO repeated its plea to increase the ratios of RNs, RPNs and NPs in nursing homes to the proper staffing skill mix. As recent as February 2019, RNAO recommended (see here and here) providing adequate staffing levels and an appropriate staffing skill mix in nursing homes. RNAO also recommended increasing the number of beds as well as changing the funding model to reward improvements in the wellness, quality of life and health outcomes of their residents. We repeated this plea, providing all the necessary evidence, in meetings and consultations with Minister of Health Christine Elliott and with Minister of Long-Term Care Minister Merrilee Fullerton, as late as March 11, the day that WHO called COVID-19 a pandemic.   

During the current pandemic RNAO has been ferociously voicing for weeks our concern in every ambit possible: at daily morning briefings with Ontario’s Medical Officer of Health, with the Ministry’s Collaborative Table of associations, through these COVID-19 reports, through the media and of course with nurses and others who write to us in desperation.

Post COVID-19, RNAO will issue a report calling for a complete overhaul of the long term care sector to make it a priority for humane, dignified and safe care. For now, we must tackle ways to mitigate the utter devastation we are all experiencing.

The latest set of government measures for long-term care was announced yesterday, representing a step in the right direction. However, government must intervene immediately, fully and vigorously. RNAO has advised for key policy measures, some of which have been adopted fully or partially by government:  

• Universal masking for all staff facing patients: This policy, which RNAO has been calling for, was adopted by government in their directive this week. However, we continue to receive multiple reports from nursing home operators, directors of nursing and staff that they do not have the necessary PPE to implement the policy.
• Pre-outbreak testing and surveillance: RNAO has been critical of the policy that has directed testing only of suspected cases among residents, in other words, only after an outbreak has started. It is urgently required that testing be used as a surveillance tool to prevent outbreaks in homes that do not yet have one. The testing guidance updated yesterday expands somewhat the span of testing but it still limited to persons demonstrating symptoms or upon admission to the LTC home. The government document directs that “Testing of asymptomatic patients, residents or staff is generally not recommended.” Thus, there is no surveillance at this time. RNAO urges once again to reconsider and establish an effective system of random testing for surveillance prior to outbreak.
• Robust case and contact tracing: RNAO has emphasized that when a COVID+ case is identified, there must be rigorous case and contact tracing, and isolation. Although this has been part of the policies in place, it is difficult to assess to what extent it has been implemented, due to lack of resources and reporting. We suspect that the resources have not been there and the action has been limited. RNAO has the human resources to support this time consuming endeavour through the VIANurse program here.   
• Self-isolation of suspect and confirmed cases: Every resident and staff suspect, and certainly confirmed COVID+, must be placed in self-isolation for 14 days. The latest directive is insufficient, since it says “Staff who have tested positive and symptomatic cannot attend work. Staff who have tested positive and have symptom resolution and are deemed critical may return to work under work isolation.” How many COVID+ workers will be considered “critical” and still be in “work isolation”?  
• Workers should work with one facility full-time rather than work with multiple employers. Again, the directive issued this week is insufficient since it states “Wherever possible, employers should work with employees to limit the number of work locations that employees are working at, to minimize risk to patients of exposure to COVID-19.” There is no requirement to act or compensation for the workers who will lose their income from not being able to work their normal assignments. British Columbia has been ahead of the curve implementing strong measures.

Late this evening, April 10, the government issued a new directive (see here), which appears to supersede the one issued earlier in the week. The new directive seems to limit the requirement of universal masking for all staff facing patients, since it states “In the event that the supply of PPE reaches a point where utilization rates indicate that a shortage will occur, the government and employers, as appropriate, will be responsible for developing contingency plans, in consultation with affected labour unions, to ensure the safety of health care workers and other employees.” We are waiting for further clarity from the Ministry and will provide updates as soon as they are available.