Tuesday, May 5, 2020

Post Mortem for Pinecrest LTC: How Systemic Flaws Led To Tragedy at a Bobcaygeon Nursing Home

Systemic Flaws, not Covid, are the REAL and ACTUAL problem(s)
"When David Adams walked into his mother’s room on March 29, tears began to silently fall down her cheeks. Nine other residents of the Pinecrest Nursing Home in Bobcaygeon, Ont., had already died of COVID-19, and visitors had been banned. Many of the home’s workers were sick, and those who were still showing up for their shifts were frantically trying to care for Pinecrest’s remaining residents.

Mr. Adams’s mom, Marguerite Adams Miller, had spent 30 years as a nurse at Pinecrest. Now 98 and living with dementia, she’d moved in nearly a year earlier. As a lifelong local in a facility filled with the same, she knew pretty much everyone.

When Ms. Adams Miller began showing signs of COVID-19, a Pinecrest nurse called her son, who insisted he be allowed to sit with her. When the worker on the other end of the phone hesitated – no family or friends were allowed inside – Mr. Adams told her that as a child, he’d missed many meals with his mother because she’d stayed late to sit with dying patients. “There’s no way she’s going to die alone,” he told the staffer.

Inside his mom’s private room, Mr. Adams found her conscious, but struggling to breathe and unable to speak. For the next 24 hours, he kept a vigil at her bedside, holding her hand and swabbing her mouth with water.

During his time inside the site of Ontario’s first major outbreak, Mr. Adams says he saw a facility in chaos, with the few remaining workers running from patient to patient, struggling to keep up with their care. During one sick resident’s intense coughing fit, a worker called for help – a plea that to Mr. Adams went unanswered for a painfully long time. There were delays getting his mother’s doses of morphine because the nurses were so busy. One personal support worker told him she was pulling a double shift because her replacement hadn’t arrived.
This is not the first time I'd read the ill and elderly were administered morphine. Yes, it keeps them comfortable.  But,it wakes me wonder what if anything was done to assist these individuals before resorting to morphine?
“In all this, they worked admirably,” Mr. Adams says. “They had nothing but love and concern for the people who were there. They were desperate to do all the right things.”

Nonetheless, his mother died on the evening of March 30, the victim of an outbreak that served as an ominous prelude to dozens of other catastrophic flare-ups inside seniors’ homes, which are now the source of more than three-quarters of COVID-19 deaths across the country"
  The harrowing outbreak in the heart of cottage country exposed troubling gaps in provincial policies that govern nursing homes, and laid bare shortcomings at the local public health unit and at Pinecrest itself that put already fragile residents at risk.
Initially, provincial policy limited testing to just three residents, (Why? During a pandemic?) leaving Pinecrest’s nurses and personal support workers – not to mention patients and their families – blind to exactly who was infected and who wasn’t. Public health failed to inform the broader Bobcaygeon community about the sheer scope of the outbreak and the dangers it posed. Inside the home, a lack of space thwarted the staff’s early infection-control measures, and an ill-fated plan to separate the sick from the supposedly healthy may have helped spread the virus.
When it was all over, nearly half of Pinecrest’s residents were dead.
When the outbreak began, most of Pinecrest’s residents were elderly, many with dementia, but a few were much younger, with health conditions requiring round-the-clock attention. Many of them had roommates; half the rooms in the single-storey building are wards, shared by four residents. There’s a small dining room for the few who are able to walk to meals and feed themselves, and a larger one for everyone else.

During the provincial government’s last in-depth inspection of Pinecrest in 2018, (2018!! That's an outrage) inspectors found black debris in bathrooms, and corrosion on lifts, transfer devices and bath chairs. The tubs were chipped and gouged from wear and tear, and some of the original wood-frame windows – which, the inspectors’ report noted, had been flagged as deficient in a previous inspection – neither opened nor closed properly. Some were perennially stuck open by an inch or two, and could only be closed if someone went outside to push them shut. The inspection also criticized Pinecrest’s infection-control practices – particularly its failure to label denture cups, urinals, razors and other personal items in shared bathrooms. In some cases, inspectors found soiled towels on the floor and urinals full of fluid
Ms. Carr said in a written response to questions that the deficiencies flagged in the 2018 inspection “were dealt with immediately.” A follow-up inspection in the spring of 2019 found the home had fixed the problems.

During past outbreaks – of influenza or other routine infectious diseases – Pinecrest staff would isolate residents in their rooms, close the privacy curtains in shared accommodations, and don gowns, gloves and surgical masks to feed and bathe the sick. In keeping with provincial guidelines, Pinecrest would test a handful of ill residents to identify the viral or bacterial culprit, then treat anyone who was symptomatic as though they were infected.

When COVID-19 first hit, Ontario’s Chief Medical Officer of Health David Williams stood by that protocol, repeatedly insisting that once the root cause of a wave of illness in a long-term care home was identified, there was no need to test further, especially with testing materials in short supply. That approach proved to be no match for COVID-19.
That approach would have been no match for any virus or bacterial outbreak-  Which is why LTC homes have always been a problem.
Quoting Jane Meadus from a previous post:
“I hate to say it, but this happens all the time in long-term care. It is constant. Every year, we have [flu] outbreaks.”
“There is always a problem, when there is an illness in the homes,” said Jane Meadus, staff lawyer with the Advocacy Centre for the Elderly in Toronto, who pointed out that seniors in care facilities are older, and more vulnerable, than ever.
"Even before anyone at Pinecrest tested positive for COVID-19, management ordered staff to wear protective gear – but only when dealing with residents who were obviously ill. By the time the outbreak was confirmed on March 20, 23 residents were already sick, says Dr. Michelle Snarr, the facility’s medical director.

Personal support worker Penny McLean remembers the news spreading through the home with little explanation from management. There was no handover meeting at the start of her 2 p.m. shift on March 20. Instead, an e-mail landed at 2:14 p.m. “Public Health has informed us that one of the swabs taken for our Outbreak has tested positive for COVID-19. Basically our plan remains the same,” wrote Ms. Carr and Shelly Griffin, the home’s director of care. The e-mail explained that all residents were to be isolated in their rooms, with staff donning procedure masks “at [the] very least” at all times. Anyone who had recently worked at other homes – a common practice for low-paid health care aides – were to inform the local public health unit immediately and stop working elsewhere "
The Public Health Unit fell down on the job as well- Systemic fail

"The same day, the Haliburton, Kawartha, Pine Ridge District Health Unit issued a news release saying COVID-19 had been lab-confirmed in three Pinecrest residents. The statement did not say, however, that many more residents and staff were exhibiting symptoms, too.
In the meantime, Hayley Chazan, a spokeswoman for Ontario Health Minister Christine Elliott, says the provincial government is doing all it can to fight a virus that is ravaging long-term care facilities. It’s dispatching hospital SWAT teams to help out, and the military has been called in to five of the hardest-hit homes. “What occurred at Pinecrest, and other long-term care homes across the province, is tragic,” Ms. Chazan says.

Mr. Adams, the son of former Pinecrest nurse Marguerite Adams Miller, wants more than words. He believes the government should call a public inquiry into how the coronavirus was allowed to wreak such havoc inside the province’s nursing homes."

“Something’s broken here,” he says. “So, if something’s broken, you’ve got to sit back and decide how you’re going to fix it.”
 Doug (Yahoo) Ford is trying to close the barn door after all the horses have gone.
The problems in Ontario's LTC were long known and the Ford government failed entirely to address them. As has been stated here previously.
Deplorable, systemic negligence killed these individuals. Doug Ford and his government need to be taken to task. Trudeau's Liberals as well. It's shocking to me. Simply shocking and disgusting that Canadians are too frightened by the perception managing media to really question the systemic negligence built into our elder care systems. Don't blame Covid. It takes the blame off the real problem and those actually responsible for it!  Don't deflect.
Finally, these problems have shown themselves, globally. Making elder care a horrible and cruel lie.  Pandemic preparation a farce. There was no preparation for prevention. 
 There was a total media terror/trauma inducement. Economic destruction. Mass bailouts for the banks, big, big business and corporations.  The lock down and traumatic media coverage was undertaken to keep us down and quiet as the massive bailouts took place.



  1. I can't bear mistreatment or neglect of little ones or old ones. This is just horrible.

    1. Hi Gwen:
      Yes, this situation has been awful to read about. Tragic for the families.

      I'm not faulting the front line staff, thinking they did what they could under awful circumstances.

      What bothers me in all this is once the situation hit critical it just went out of control.

      And that's what bothers me. It never should have gotten to the stage it did. Kingston got it right, Kudos to them and they show very clearly that what occurred did not have to.

      The lawsuits have started to be filed. It won't bring any of the lost ones back. There is some speculation that the Ford government could just pass a law making themselves not accountable-


      ""Premier Ford described the situation occurring in long-term care and retirement homes as a 'wildfire,'" said Pinta Maguire, partner and head of the medical malpractice section at Toronto-based Tyr LLP, the law firm behind the proposed class action.

      "And the core of this claim is that this is a fire that should never have started.""

      It really shouldn't have. The Ford government did nothing to prevent it. Nothing. Yes, sadly, the buck will be passed

  2. Well, I didn't want to be pessimistic in my comment, but you know they're going to find some way to CYA. I assumed that since these reports have come out they're busy trying to find a way to be blameless. As you said, they'll no doubt try to use the "pandemic" as an excuse, which most people will believe.

  3. " As you said, they'll no doubt try to use the "pandemic" as an excuse, which most people will believe."

    Sadly. My hope is by shedding some light on reality some truth will be known.