TORONTO -- A military report released Tuesday shed light on the "gut-wrenching" conditions of five long-term care homes in Ontario during the COVID-19 pandemic.
The Canadian Armed Forces (CAF) report, written by Brigadier-General C.J.J. Mialkowski, outlines the grim state inside the facilities, claiming not only that there were staffing shortages and lack of personal protective equipment (PPE), but also that there were bug infestations, old food trays stacked inside resident rooms and that patients were observed “crying for help with staff not responding.”
Last month, Canadian soldiers were sent to facilities in Ontario to help staff struggling to deal with severe COVID-19 outbreaks that resulted in resident deaths.
The homes included Orchard Villa in Pickering, Altamount Care Community in Scarborough, Eatonville Care Centre in Etobicoke, Hawthorne Place in North York and Holland Christian Homes' Grace Manor in Brampton.
The CAF report was presented to the provincial government over the weekend and read in full by Canadian Prime Minister Justin Trudeau on Monday.
Based on two weeks of observation, the CAF said they identified a number of medical, professional and technical issues at all five long-term care homes.
Among them were significant allegations claiming that staff used the same PPE—gloves, masks and gowns—while treating multiple patients. In at least one of the homes, the CAF said that patients who were COVID-19 positive were allowed to wander through the facility.
Military members said they witnessed residents “crying out for help” while waiting anywhere from 30 minutes to two hours for a staff member to respond.
The report also claims that some residents were force fed to the point where audible choking could be heard.
In two of the homes, military members reported seeing bug infestations, including ants, cockroaches and flies.
MORE: Families who lost loved ones at Ontario's worst-hit nursing home fear they were left to die
Speaking at Queen’s Park on Tuesday following the release of the report, Premier Doug Ford said that his government didn’t know the “full extent of what these homes, what these residents were dealing with” until Monday morning.
"The reports they provided us were heartbreaking, they were horrific, it's shocking that this can happen here in Canada. It's gut-wrenching and reading those reports was the hardest thing I've done as premier,” he told reporters.
"What I am feeling, what we all are feeling is little in comparison to the hardship that these residents and their families have had to endure."
The premier then proceeded to promise “justice for these residents and their families” and said that the government has launched a full investigation into the allegations, including an investigation by Ontario’s Chief Coroner.
“The results of these investigations will be shared with police to look into any possible criminal charges and I will also make the results of these investigations public,” he said.
Here are some of the allegations presented in the CAF report:
Eatonville Care Centre - Etobicoke, Ont.
At Eatonville Care Centre, where at least 42 residents died after contracting COVID-19, the military alleges that residents who had tested positive for the disease were left to wander throughout the facility. They also claim that staff “are under the impression” that they don’t need to change their PPE if they are treating two residents who both have the same infection.
CAF reported that there was a “general culture of fear” among staff in terms of using supplies “because they cost money” and that key supplies were often locked away and not accessible. They also said that residents who routinely soil themselves were not allowed an extra soaker pad or towel to protect their sheets. The report goes on to say that “PSWs are afraid for their jobs on this issue.”
The report also cites “aggressive behaviour” that military members described as “abusive/inappropriate.”
“Examples include aggressiveness when changing incontinence products, not stopping or slowing when resident complained of pain, pulling residents, aggressive transfers impacting resident ability to participate in care as able (roll self in bed,) degrading or inappropriate comments directed at residents ect.”
Other allegations include:
- Reusing hypodermoclysis supplies “even after sterility has been obviously compromised”
- Inadequate dosing intervals for some medications
- CAF reported nearly a dozen incidents of “bleeding fungal infections” due to poor peri-catheterization car
- The facility is understaffed during the day and new staff haven’t been trained or oriented
Hawthorne Place Care Centre - North York, Ont.
At Hawthorne Place, where at least 39 residents have passed away as a result of COVID-19, the military described a “significant deterioration of cleanliness standards,” including “significant gross fecal contamination” in numerous patient rooms as well as ants and cockroaches. They also said that military members witnessed “forceful feeding” of residents, causing “audible choking.”
Other allegations include:
- Nurses and PSWs observed not changing PPE for several hours while moving between patient rooms
- Topical prescription medicine shared between residents
- Wound care supplies “insufficient or locked away”
- Shortage led to residents sleeping on beds with no linen, which resulted in “increased skin breakdown”
In a news release issued Tuesday evening, Hawthorn Place said that the details of the report concering their facility were "devastating to read."
"We will review each item in a detailed manner with our full leadership team and we will be active participants in any investigations that occur with the Government of Ontario, provincial Ministries, and the Canadian Armed Forces."
Orchard Villa - Pickering, Ont.
Orchard Villa has been one of the hardest-hit long-term care homes, with at least 77 residents dead and 346 infected. More than 90 staff members have also been diagnosed with COVID-19. At the top of the CAF report, Mialkowski notes that cockroaches and flies were “present” and the hallway outside a patient’s room smelled of rotten food.
The report also said that patients were being left in beds “soiled in diapers” rather than being moved to the bathroom.
In one of the more serious allegations, Mialkowski says that PSWs and nurses aren’t always sitting residents up while feeding them or giving them medication. He goes on to say that in one observed incident “that appeared to have contributed in patient death.”
Other allegations include:
- Inappropriate use of PPE by all staffing levels, including doctors
- Staff put food and important belongings outside of residents' reach
- Lack of linens and laundry resulted in patients sleeping on bare mattresses
- Multiple falls without required assessments
- Patients were moved into rooms that were not cleaned due to miscommunications
Altamount Care Community - Scarborough, Ont.
At least 52 residents at Altamount Care Community have died after contracting COVID-19. The CAF report alleges that staffing issues have led to inadequate nutrition at the facility and that most residents reported not having received three meals per day.
The report also indicated that at the time of the military’s arrival, many of the residents had been “bed bound for several weeks” and that there was no evidence of residents being moved to a wheelchair, repositioned in bed or washed properly. A number of residents had pressure ulcers “as a result of prolonged bed rest,” the report said.
Other allegations include:
- A non-verbal resident wrote a letter alleging “neglect and abuse by a PSW”
- Safety concerns regarding the clinical skills of staff
- Insufficient wound care materials and supplies
- The current staff to patient ratio does not allow for care beyond “the most basic daily requirements.”
- Staff members avoid shrouding or providing post-mortem care to deceased patients and leave it to military staff
Holland Cristian Homes’ Grace Manor - Brampton, Ont.
At Holland Christian Homes' Grace Manor, where at least 11 residents have died after contracting COVID-19, there were reported incidents of staff moving from COVID-19-positive areas to other units without changing PPE. The report also found that staff wore the same pair of gloves for several tasks involving different patients and they were cleaning the gloves with hand sanitizer.
The military also said there were reports of staff not assisting residents during meals.
“Staff would rather write the resident refused to eat rather than helping them,” the report alleges.
Other allegations include:
- Leaving food in a resident’s mouth while they are sleeping
- Aggressively repositioning a resident
- Improper sterile technique with dressing changes
CAF recommends staying at homes for another 30 days
The military report did note that conditions at the long-term care facilities have improved since they arrived and that a military presence has had “an immediate effect on both daily operations and incremental facility recovery.”
“From a command and medical perspective, challenges were expected at these facilities given the severe deficiencies and shortfalls that existed/exist at the provincially-prioritized assignments,” the report said. “The CAF was meant to go to locations with the greatest need of our support. This is a reflection of the conditions of those distressed locations.”
‘Someone should have listened to us’
Families of residents living at Orchard Villa gathered outside the facility after learning about the military report, urging the government to take action rather than simply express remorse.
The home has been the subject of multiple lawsuits, the most recent of which was a $40 million class-action filed on Tuesday alleging neglect.
Speaking outside Orchard Villa, Toronto area resident Cathy Parks, whose father passed away in April, said that while she knew about the allegations around dehydration and lack of nutrition, there was a lot that she wasn’t aware of.
“I was shocked,” she said. “They are not being given a fighting chance.”
“I think it’s been criminal what’s been going on. I think it needs to be dealt with.”
June Morrison, whose father George Morrison also passed away after contracting COVID-19, is filing a lawsuit of her own claiming that his death occurred as a “direct result” of negligence and breach of contract.
On Tuesday she said that most of what was in the report wasn’t surprising.
“We knew that there were bad things going on in inside. This report is only confirming what we already knew,” she said. “Someone should have listened to us weeks and weeks ago. We had inside knowledge.”
“A lot of people in this group have family in that home right now and how do you see something like that and know that is going on and not want to drive over here and pull them out of the home.”
The buck stops with Ford, union says
A union representing more than 60,000 healthcare and community service workers across Ontario said they welcome the CAF report on disturbing conditions within the long-term care homes.
“Our union and our frontline members have been ringing the alarm bells throughout this entire crisis. Unfortunately, we have had to fight the provincial government every step of the way to ensure long-term care companies were keeping workers and residents safe,” Service Employees International Union President Sharleen Stewart said in a statement on Tuesday.
Stewart said that the province’s decision to eliminate regulations that required background checks for new hires “was a recipe for disaster” and that they ignored their pleas for more inspections and investigations into the condition of long-term care homes.
“Instead of helping, Doug Ford has made long-term care worse for workers and residents,” she said. “Doug Ford has refused to take action on increased staff-to-resident ratios. Doug Ford has capped the wages of the lowest-paid workers in long-term care. Doug Ford eliminated paid sick days for vulnerable essential workers. Doug Ford has limited inspections in long-term care. These decisions came from his desk.”
“The buck stops with him.”
Report is ‘deeply disturbing,’ PM says
Speaking with reporters on Tuesday morning at his daily COVID-19 briefing, Trudeau said the report made him feel angry and called it “deeply disturbing.”
"There are things in there that are extremely troubling and we need to take action," Trudeau said. "I spoke with the premier this morning to ensure him that, of course, the federal government would be there to support them as they deal with this situation."
Deputy Prime Minister Chrystia Freeland also read the report on Monday and called it “truly heart-wrenching” while addressing it on Tuesday afternoon.
“Our government took it very seriously and acted very quickly,” she said. “When we received the report we shared it with Ontario.”
Freeland added that it is “important to be careful with devastating information like this.”
“(We need) to be sure it’s accurate – it’s also really important for Canadians to know what’s happening so that we can all act.”
More than 1,500 long-term care residents in Ontario have died after contracting COVID-19 as well as six health-care workers.
With files from Kayla Goodfield
Graphic warning: Here is the full report from the Canadian Armed Forces. Details included in the report may be disturbing.
