Maples Long Term Care Home was severely short-staffed and unprepared to care for extremely ill seniors during an intense COVID-19 outbreak — in which 56 residents died — while appeals for help were initially unheeded, an external review has concluded.

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Maples Long Term Care Home was severely short-staffed and unprepared to care for extremely ill seniors during an intense COVID-19 outbreak — in which 56 residents died — while appeals for help were initially unheeded, an external review has concluded. 

Lynn Stevenson, a former associate deputy minister in the B.C. Ministry of Health and registered nurse, outlined the findings of her review into Manitoba’s largest and deadliest personal care home outbreak on Thursday. 

"The pandemic plans, while they were very robust and comprehensive, did not take into consideration what happened at Maples, which was the precipitous and significant loss of staff over a very short window of time," said Stevenson, who appeared at a news conference virtually with Health Minister Heather Stefanson and Winnipeg Regional Health Authority chief health operations officer Gina Trinidad.

Stevenson authored a 74-page report detailing the response to the outbreak at Maples by the operator, Revera Inc., the WRHA and the provincial government, following an external review which included interviews with care home staff, family and regional executives as well as reviews of planning and clinical documents.

Speaking via livestream, Dr. Lynn Stevenson said the Maples Long Term Care Home was severely short-staffed and unprepared to care for extremely ill seniors during an intense COVID-19 outbreak. (Mikaela MacKenzie / Winnipeg Free Press)

Speaking via livestream, Dr. Lynn Stevenson said the Maples Long Term Care Home was severely short-staffed and unprepared to care for extremely ill seniors during an intense COVID-19 outbreak. (Mikaela MacKenzie / Winnipeg Free Press)

She provided 17 recommendations to Revera, the WRHA, the health incident command structure and Manitoba Health.

On Thursday, Stefanson promised to act on the recommendations related to staffing, care and infection prevention, funding and management of the province's long-term care facilities.

The outbreak at Maples, a 200-bed facility in northwest Winnipeg, was declared on Oct. 20 when one resident tested positive for the coronavirus. Revera tested all residents and by Oct. 29, 96 residents had been diagnosed with COVID-19 and many staff were off sick.

On Nov. 6, paramedics responded to multiple 911 calls from the care home, as staff struggled to keep up while the condition of numerous residents infected with the virus deteriorated. Eight residents died in a 48-hour period that weekend. Between Nov. 2 and Nov. 14, the province reported that 26 seniors had died after coming down with COVID-19 at Maples.

By the time the outbreak had concluded on Jan. 12, 231 people had been infected, including 157 residents and 74 staff. Fifty-six residents died.

"This was a tragedy for the residents, their families and for the staff caring for them," Stefanson said.

Stevenson said Revera made "significant efforts" to bring in staff to the home. It was clear to the operator by Oct. 23 that it would need support and it made requests for additional staffing to the provincial recruitment and redeployment team (PRRT) for help. It began reaching out to nursing agencies and other institutions to find staff.

On Oct. 26, Revera asked for staffing support from the COVID-19 provincial pool and the PRRT, the report said. On Oct., 28 and 29, Revera notified the WRHA of staffing and contact tracing concerns and asked Shared Health to send staff.

'There was one nurse for 100 residents'

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Lynn Stevenson, external reviewer, speaks virtually at a press conference about the results of the review of the deadly COVID-19 outbreak at Maples Care Home. (Mikaela MacKenzie / Winnipeg Free Press)
Lynn Stevenson, external reviewer, speaks virtually at a press conference about the results of the review of the deadly COVID-19 outbreak at Maples Care Home. (Mikaela MacKenzie / Winnipeg Free Press)

Posted: 6:54 PM Feb. 4, 2021

The daughter of a senior who died in a COVID-19 outbreak at the Maples care home, in which 56 lives were lost, said she doesn't trust the review that probed the crisis.

Minutes after the province released the external probe, Eddie Calisto-Tavares called for the resignation of the chief health operations officer of the Winnipeg Regional Health Authority, Gina Trinidad. She also wants the provincial government to take responsibility for its failure to prepare care homes for the second wave of the pandemic last fall.

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By Oct. 30, staffing levels were critical, the report states. Between Oct. 30 and Nov. 8 there were numerous shifts in which staffing levels for both nursing and health care aides were below 70 per cent, dipping to as low as 33 per cent.

"The staffing shortages at Maples should have triggered a system-wide response involving provincial incident command, SWAT teams, mandatory redeployment, and potential emergency orders. This did not occur," Stevenson wrote in the report.

The province’s health incident command structure had only been reinstated (after standing down over the summer) on Oct. 30, 10 days into the outbreak. There was only one certified WRHA infection control practitioner to cover 38 sites.

The critical staffing levels at Maples were not being communicated to incident command, despite questions being raised by its members, Stevenson wrote.

"There appeared to be frequent communication between Maples leadership and WRHA at the beginning of the outbreak, but it is unclear how decisions were made or escalated," Stevenson said. She also noted members of incident command and WRHA senior staff indicated they were not fully aware of the staffing crisis.

Members of the Winnipeg Police Identification Unit dressed in protective equipment enter the Maples Long Term Care Home in November. A total of 56 residents died during a COVID-19 outbreak. (Daniel Crump / Winnipeg Free Press files)</p>

Members of the Winnipeg Police Identification Unit dressed in protective equipment enter the Maples Long Term Care Home in November. A total of 56 residents died during a COVID-19 outbreak. (Daniel Crump / Winnipeg Free Press files)

On Nov. 2, regional and provincial health officials visited the home unannounced. Following the events of Nov. 6, a paramedic rapid response team was stationed at the home and WRHA clinical leads began providing direct oversight.

When questioned by reporters Thursday, Stevenson said she doesn’t know why staffing support wasn’t given before the situation at Maples became critical.

However, she said the level of urgency in the requests by the operator may not have been fully appreciated by provincial and regional health authorities.

"It’s not as if the staffing over time got shorter. This was fairly precipitous," Stevenson said.

"You have 10, 15 people going off at one time and then trying to replace that staff and they did not have the mechanisms in place" for immediate redeployment, she said.

"So that’s part of the lesson in this."

Widespread recommendations

The review into the handling of the COVID-19 outbreak at the Maples care home includes 17 recommendation

Revera

• Revise the Maples outbreak plan to ensure the ability to operationalize it

• Implement clear care priorities for residents during an outbreak, including medication management

• Mobilize and deploy additional onsite Revera resources at the beginning of an outbreak

• Ensure daily on-site physician rounds are in place once an outbreak has been declared

• Recognize housekeeping is a critical essential service

• Improve communication

The review into the handling of the COVID-19 outbreak at the Maples care home includes 17 recommendations. 

Revera

• Revise the Maples outbreak plan to ensure the ability to operationalize it

• Implement clear care priorities for residents during an outbreak, including medication management

• Mobilize and deploy additional onsite Revera resources at the beginning of an outbreak

• Ensure daily on-site physician rounds are in place once an outbreak has been declared

• Recognize housekeeping is a critical essential service

• Improve communication

Winnipeg Regional Health Authority

• Revise the pandemic plan to ensure adequate support for care homes

Provincial Level (health incident command structure)

• Simplify and clarify communication and decision-making roles between WRHA and Health Incident Command Structure Planning Tables.

• Co-ordinate and prioritize the multiplicity of information, directives and guidance documents being pushed out to the care-home sector by a variety of sources.

Provincial Level (Manitoba Health and Seniors Care)

• Mandate and fund a provincewide health-care system response for pandemic outbreaks to reduce fragmentation and delays in outbreak response.

Additional Considerations

• Review funding for care homes to ensure staffing levels and services are appropriate to the complexity of current and future residents.

• Streamline licensing standards for care homes to ensure currency and applicability to the changing needs of residents.

• Given the impact of an outbreak of this magnitude, work must be done to rebuild trust with families. Consideration must be given to staff who have been negatively impacted by the experience and the amount of media scrutiny.

— source: Maples Personal Care Home Covid-19 Outbreak: External Review Final Report

The WRHA has since established a central staffing model for personal care homes, Trinidad said.

Stevenson also noted that it was not readily apparent that clinical guidance was being offered to health-care providers looking after residents who had COVID-19.

"There was little evidence of resources and guidelines to equip staff on-site with clinical skills required to manage acutely ill COVID-19 positive residents in (long term care) PHCs. This includes consideration of staffing ratios that would support this clinical care and expectations related to on-site physician presence," she wrote.

Stevenson could not comment on whether earlier intervention by the WRHA and provincial authorities at Maples could have led to fewer infections or deaths.

"Would it have been helpful to have had more people on site? Yes, it likely would have been. Would that have prevented the deaths? I can’t say," Stevenson said.

Trinidad said the health authority is reviewing every death at personal care homes, including Maples, to see whether there are grounds to declare a critical incident.

Winnipeg Regional Health Authority chief health operations officer Gina Trinidad (from left), external reviewer Dr. Lynn Stevenson, and Health Minister Heather Stefanson release the results of the Maples Long Term Care Home review on Thursday. (Mikaela MacKenzie / Winnipeg Free Press)

Winnipeg Regional Health Authority chief health operations officer Gina Trinidad (from left), external reviewer Dr. Lynn Stevenson, and Health Minister Heather Stefanson release the results of the Maples Long Term Care Home review on Thursday. (Mikaela MacKenzie / Winnipeg Free Press)

Stefanson meanwhile said she has apologized to families who have lost loved ones, but did not say if her government accepts responsibility for the tragedy.

"Certainly what they have gone through is absolutely tragic," Stefanson said. "I think what’s very important here is that we learn from mistakes that are made and how we can make things better and safer for both the residents as well as the staff who work in those homes."

Stefanson said the province and health authority have started to address the report's recommendations, including training for staff, strengthening pandemic staffing plans, enhancing care plans for residents and bolstering communications with families.

The province is working to update visitation guidelines, strengthen communication between sites, implement asymptomatic rapid testing for staff and improve infection prevention and control procedures.

Stefanson said an implementation team has been formed to provide a publicly available plan to address the recommendations within 30 days, with updates expected every 90 days.

danielle.dasilva@freepress.mb.ca

Danielle Da Silva

Danielle Da Silva
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Danielle Da Silva is a general assignment reporter.

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