Oversight of infection control measures — key to keeping long-term care homes free of illness — plummeted when Ontario scaled back comprehensive annual inspections last year.
Infection control violations would typically be caught during so-called resident quality inspections (RQIs), but a CBC News investigation found that the number of violations dropped off along with the number of RQIs in 2019.
The inspections in long-term care homes fall primarily into two categories: complaint and critical incident inspections, which are reactive, and RQIs, which are broader and proactive.
Homes get written up for violations that could include incorrect use of personal protective equipment, failing to clean shared washrooms and insufficient training in protocols for minimizing the spread of viruses.
CBC reviewed reports from 2014 to 2019 and found infractions such as leaving soiled bedpans on safety handrails; “not performing hand hygiene before serving food to other residents”; failing to place isolation signs on doors of sick residents; “black debris … on tubs and walls”; improper cleaning of wounds, leading to infection; and “one nurse dropped pill on the ground and still fed to resident.”
CBC News found that 87 per cent of infection control violations are discovered through RQIs. But there was a significant drop in RQIs since the end of 2018, from almost every home getting a proactive inspection in 2016 and 2017, to only nine receiving an RQI in the year before COVID-19.
Along with the decrease in RQIs, the number of recorded infection control violations at Ontario’s 626 long-term care homes also dropped. They ranged from 150 to 250 per year for 2014 through 2017, but only 50 were recorded in 2019.
‘They’re not looking for them’
Advocate for the elderly and lawyer Jane Meadus says the dramatic drop in violations is not an indication that protocols are improving.
“You can’t find something if you don’t look for it,” said Meadus, of the Advocacy Centre for the Elderly. “They’ve stopped doing RQIs. It is inevitable that those kinds of findings are going to drop to zero because they’re not looking for them.”
Ontario’s Ministry of Long-Term Care told CBC News it scaled back comprehensive RQIs to focus on complaints-triggered inspections starting in the fall of 2018.
But Meadus said that’s not enough.
“The things that people complain about are not the same things that are looked at in an RQI,” she said.
And she says focusing on homes with more complaints could actually have the opposite effect. Homes that might have a lot of issues “may, in fact, not actually have a lot of complaints.”
“There’s a lot of homes that are what a lot of people think of as good homes that have a lot of complaints because [residents] have some family members that are ready to complain if something goes wrong.”
Advocate ‘worried sick’
Laura Tamblyn Watts, a lawyer and advocate at the National Institute for Care of the Elderly, says she is “worried sick” about the government’s move to complaints-based inspections and the drop in infection oversight.
“Infection control is critically important in long-term care,” she said. “When you have a closed ecosystem, which is kind of what a long-term care setting is … we know that the infection vector is coming in and out through staff members.”
“There are horror stories that are happening right now with regards to COVID-19,” she said.
Pinecrest Nursing Home, in Bobcaygeon, Ont., where 29 people have died since a COVID-19 outbreak began, was handed a notice in 2018 for failing to wash privacy curtains “after another resident in a shared room had been sick and/or coughing on the curtains.”
They received another written notice after “a soiled basin was observed in the sink, a soiled towel was observed on the floor, and a urinal was observed on the toileting safety handrails in the washroom.” The report noted that the washroom was “shared by four residents.”
At Eatonville Care Centre in Toronto, where 31 residents have died, a 2017 RQI found that multiple residents during a different kind of outbreak had been “demonstrating symptoms in the past six months” and that these symptoms were not documented “until the residents were receiving treatment for their symptoms.”
The report went on to say there was “soiling” on the walls and on a light fixture still present a week after it was discovered.
The ‘most susceptible people’
Despite the drop in RQIs, the ministry says every home gets inspected through a critical incident or complaints-based inspection “at least once a year,” and that Ontario’s long-term care home inspections “continue to be the most rigorous in Canada.”
Most homes do get a visit from the Ministry at least once a year to investigate complaints or critical incidents, but the data shows that at St. Clair O’Connor Community Nursing Home, where seven have died from COVID-19, there was no inspection of any kind in 2018.
Meadus says the lack of RQIs could have contributed to the current crisis Ontario is facing. As of Thursday, the province said that 104 homes have COVID-19 outbreaks.
“I think that they should have been monitoring, looking at infection control,” Meadus said. “The government didn’t seem to recognize that the homes were very likely to have outbreaks, even though you have outbreaks of flu every year at these homes.”
She says all homes should have been prepared for an infectious outbreak at any time with sufficient protocols and personal protective equipment.
“Why didn’t these homes have those kinds of equipment in their homes just for the flu epidemics? You know, just regular old flu influenza that goes through these homes.
“The homes should be well-stocked with these things because they are the most susceptible people,” she said.