At the height of the first wave, a staff person at the Orchard Villa long-term care home reported to a provincial government inspector that “there is no staff to feed and care for residents, and that living conditions are like hell.”
But at the time, ministry inspectors did not enter homes, “so there was little external oversight as homes struggled to meet residents’ basic needs,” the Ontario Ombudsman wrote in a report released Thursday.
Without eyes on the ground, the ministry’s inspection branch was so out of the loop, that it wasn’t aware that there were staffing and personal protective equipment shortages at the Orchard Villa as the outbreak was worsening and residents were dying.
At the end of the month, the Canadian Armed Forces came in to stabilize the home. Seventy residents died there in the first wave.
Paul Dubé’s report on the “collapse” of the long-term care inspection system comes more than three years after that deadly initial wave of the pandemic, but the ombudsman said his findings are still critical to ensuring the government is ready to meet the next pandemic when it comes.
Not only were inspectors not going into homes — for lack of personal protective equipment and infection prevention and control training, and an order from management — the government had “rebranded” the ministry’s complaints line into a “Family Support and Action Line,” where inspectors conveyed “key messages,” resulting in confusion, and inspectors failed to follow up on serious complaints in a timely manner, or at all.
Inspectors also spent time holding check-in calls with long-term care homes but many large chains refused to attend them, considering them a waste of time, Dubé found.
“For an extended period, the ministry’s oversight of the sector was essentially non-existent, as its primary tool for assessing the living conditions within Ontario’s long-term care homes — on-site inspections — was shelved,” he wrote.
Dubé’s report recounts one case in April 2020 where “Gemma” (a pseudonym) complained to the ministry that her parents’ long-term care home, Mon Sheong in Toronto, was “severely short” on personal support workers. One of her parents had died of COVID, and the other was sick.
“Gemma said residents were not being fed, cleaned or given their medications,” wrote Dubé.
“A ministry inspector ‘reassured’ Gemma over the phone and then closed the file without taking any action. Thirty-three residents died at that long-term care home during the first wave. It’s impossible to know what might have happened if the ministry inspectors had diligently followed up on complaints like (these) when they were received.”
The inspector “reassured” Gemma that people “may feel frustration, sadness and even anger in light of this situation,” the Ombudsman wrote. While the inspector told her that her complaints would be “passed further” the inspector closed the file.
Dubé chronicled a tragicomedy of errors in his report. Management’s order to cease on-site inspections was unknown to senior decision-makers in the government and counter to a plan approved by cabinet. In March, the inspections branch began implementing a new computer program that could electronically deliver inspection reports to homes, but had trouble installing it on computers.
That was one reason they didn’t issue any reports to homes during the first wave — and the other was they weren’t conducting inspections, as on-site inspections did not resume until May 2020, and June in Hamilton. Without issuing reports, they couldn’t follow up to ensure compliance with their orders.
And the ministry had failed, completely, to plan for how to conduct inspections during a public health emergency, despite news of COVID-19’s spread around the world earlier in the year. Planning stopped, the report said, when the memory of the 2003 SARS outbreak dimmed.
The ministry was also short-staffed, with only 152 of 171 inspector positions filled at the end of the first wave.
“Ministry officials explained to us that maintaining a lower staffing level was a deliberate decision, resulting from internal financial pressure,” the report says.
Overall, Dubé found inspectors rarely ordered homes to fix problems immediately, even when residents were at risk of serious harm. They also took a “narrow view” of what they could inspect, leaving residents in danger. When they did act, they often opted for lower-level enforcement actions than required by their own procedures and did not follow up to ensure compliance.
He issued a series of recommendations concerning on-site inspections, emerging public health threats, and ensuring all complaints alleging risk of harm are actually investigated.
Dubé also recommended strengthening whistleblower protections so witnesses to wrongdoing can come forward and be protected.
The Ombudsman said he’s pleased that the government has accepted all of his recommendations.
“We hear that they’ve hired more inspectors. There's a new law, but it remains to be seen with what vigour inspections are carried out and what kind of enforcement is imposed when shortcomings are found,” Dubé said.
The new minister of Long-Term Care said the government has made progress on over half of the Ombudsman's recommendations.
"COVID-19 was an unprecedented global event with devastating impacts on long-term care homes around the world. The lessons learned from this have ensured we take action by creating a new investigations unit that can refer charges when necessary and introducing new monetary penalties for bad actors," said Stan Cho, who was shuffled into the role this week, in an emailed statement.
"We will use this report to build on this work to ensure safe, high-quality care is delivered to seniors in long-term care homes across the province."
The most egregious things he learned, Dubé told reporters, were the individual stories where the ministry was warned of devastating outbreaks and failed to take appropriate action.
For instance, the report details a call to the Family Support and Action Line, where a family member of a resident called three times about the rapid spread of the virus at Extendicare Guildwood and the home’s “horrific” staffing levels.
The ministry staffer offered “key messages” and closed the case without referring it for inspection.
“It’s a miserable fail,” a ministry official later told the Ombudsman’s office, when asked about that case. “It’s, yeah, these are the ones that break my heart.”
This story was updated after its initial publication with a statement from the minister of Long-Term Care.