Oversight 'largely collapsed' at Ontario long-term care homes during devastating first wave of COVID: Ombudsman

The Ombudsman's reported noted roughly 2,000 deaths between January and August, 2020. In one case, a resident’s son complained three times about deteriorating conditions before an inspection was carried out — six months after her death.

Oversight 'largely collapsed' at Ontario long-term care homes during devastating first wave of COVID: Ombudsman
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Elderly Ontario residents are demanding answers into why the province failed to keep them safe during the COVID pandemic.

According to Ontario’s Ombudsman Paul Dubé, the Ministry of Long-Term Care was “unprepared” during the first wave and failed to frequently and adequately inspect subpar facilities.

In a new report, Dubé learned that inspections stopped for at least seven weeks in many areas, with no reports issued for two months in spring 2020.

“Few knew that this oversight mechanism had fallen apart,” he said in the report, Lessons for the Long Term. It detailed the testimonies of families who “tried in vain” to entice action from the ministry but to no avail. 

In one case, a resident’s son complained thrice about deteriorating conditions. An inspection did not occur until six months after her death.

From the onset of the pandemic to April 2022, 4,335 long-term care residents and 13 staff members reportedly died from COVID, with another 41,000 confirmed infections.

“Tragically, the Ministry of Long-Term Care was unprepared and unable to ensure the safety of long-term care residents and staff during the pandemic’s first wave,said Dubé.

In April, 2020, a staffer at the Orchard Villa home in Pickering called Long-Term Care Ontario to report “there is no staff to feed and care for residents, and that living conditions are like hell.” Lockdown measures implemented at that time prevented family members and loved ones, who were providing elderly care, from accessing their beloved seniors.

Many facilities had upwards of 80% of staff who tested positive for COVID-19, leading to considerable staffing shortages, while “Homes […] were allowed months to deal with issues that were causing serious harm to residents,” acknowledged the Ombudsman.

While some non-compliant nursing homes received written notices over orders, others did not even receive a notice — despite repeated findings of non-compliance.

Legislation in place since 2017 would have permitted the government to fine non-compliant homes up to $100,000, but the province only proclaimed that into law in 2021 under the Fixing Long-Term Care Act.

According to the Ontario Ombudsman's report, approximately 2,000 long-term care residents died between January 15, 2020, and August 2 of that year.

At the time, inspectors refused to enter homes because they lacked access to masks and training in infection prevention and control. For a period, they resorted to over-the-phone check-ins until on-site inspections resumed.

“Even when the inspections resumed, and violations of the law were found, the inspections branch often took the least severe enforcement action available, even in serious situations,” said Dubé.

“The direct result of the lack of inspections, reports and enforcement, was a lack of protection for residents and staff, and a lack of accountability for the system.”

The Ombudsman condemned the inspectors for drafting “confusing” and “poorly written” reports on the functionality of non-compliant homes.

When the Ontario Tories formed government in 2018, the Long-Term Care Ministry eliminated wide-ranging inspections to prioritize critical incidents. After years of ‘comprehensive inspections,’ the province only inspected nine of its 627 nursing homes.

Newly-named Long-Term Care Minister Stan Cho has said his government spent $72.3 million to double their inspection staff, and launch a new regime to better address complaints and critical incidents.

“The lessons learned from this [COVID] 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,” he said in a statement.

As part of the Ombudsman’s report, Dubé made 76 recommendations, of which the province accepted all. 

Long-Term Care Ontario will update him every six months on their progress to regularly train inspectors, maintain adequate mask stockpiles, and conduct on-site inspections as required.

It was well known by January 2021 that an astonishing 81% of COVID-19 deaths during the first wave in the Spring of 2020 were in long-term care homes. 

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