PDF Version: The Tragic Effects of COVID-19 in the Long-Term Care Sector
Matters Commented On: Chief Medical Officer of Health (CMOH) Orders 09-2020 and 10-2020
Close to half of Canada’s 1300 COVID-19 deaths have occurred in long-term care facilities, with the number of fatalities expected to grow in the coming weeks. News reports reveal shocking conditions in Canadian long-term care homes, including residents in critical condition abandoned by staff, workers without protective equipment, residents begging to die, and conditions so bad that criminal charges may be laid. The situation in Quebec is so dire that the government has implored doctors and other health professionals to help and has requested that the federal government provide military assistance. This blog post addresses the vulnerabilities that COVID-19 has exposed in the long-term care sector, the steps governments have taken to slow the pandemic, and improvements that must be made to better protect residents in the future.
The Impact of COVID-19 on Residents and Staff
COVID-19 outbreaks are plaguing long-term care homes across the country. For example, 72% of the residents (139 residents) at a Laval, Quebec facility have COVID-19 and 26 have died. According to nurses at that home, residents are “confused”, “trapped in their room to limit the spread of the virus”, “don’t understand what’s happening”, and “[t]heir family isn’t there.” These nurses also expressed concern regarding working conditions, noting that “we need to wear the same mask, the same gowns, the same gloves between each patient.” Another nurse, who was symptomatic, says that she returned to work after being reprimanded by her employer for staying home while awaiting test results. She later tested positive for COVID-19.
At a 65-bed home in Bobcaygeon, Ontario, 29 residents have died and 28 staff have tested positive for the disease. The medical director of that facility referred to the situation as a “war zone” and “gut-wrenching.” According to a Bobcaygeon City Councillor, the personal support workers and nurses say “there’s going to be PTSD afterwards because it’s so stressful” and workers have been doing 12-hours shifts without a day off in weeks.
In a particularly tragic case, the Quebec government became involved after 31 residents of a Montreal long-term care facility died over the course of a few weeks. Although the facility owner initially withheld medical files, at least 5 of these deaths have now been linked to COVID-19. According to family members and nurses who were deployed to assist, there were very few staff members remaining and residents lacked food and water, had not been given medication, had week old dressings, and were covered in feces. Two residents who were found in critical condition later died. Nurses allege that they were instructed by their employer to work, despite being symptomatic, and were not provided with protective equipment. Quebec’s premier said that this “certainly seems like gross negligence” and the coroner and police are investigating. A class action alleging “inhuman and degrading treatment” has already been filed.
In Alberta, Calgary’s McKenzie Towne Continuing Care Centre is home to the province’s largest outbreak with 22 deaths so far. The facility has struggled to meet staffing requirements, given that almost 40 staff members have tested positive. According to nurses, the situation is “heartbreaking”, as they are scrambling to meet the increasingly acute medical needs of deteriorating patients with limited staff. One nurse reported that she had to care for 21 patients without the help of any health care aides. Nurses have also expressed concerns with infection control, including insufficient cleaning and symptomatic residents sharing rooms with healthy residents.
On Friday April 17, Alberta Health Services assumed operational control of a long-term care home near Peace River due to its failure to maintain infection control standards. The Manoir du Lac, which houses 62 residents, has had 5 deaths and there are 37 confirmed cases of COVID-19 there. Given that the mortality rate is so high among long-term care residents who have COVID-19 (33.7%, according to one study), many additional residents are likely to die there.
Government Actions to Protect Residents and Workers
Throughout the COVID-19 outbreak, Alberta has implemented various measures to protect long-term care residents and staff. However, some argue that these steps were not taken soon enough. For example, while visitors to long-term care facilities were restricted on March 20, they were not prohibited (subject to very narrow exceptions) until April 7. Similarly, it was not until April 17 that the government announced its intention to test all residents and staff (including those who are asymptomatic), despite the fact that some jurisdictions had already been doing this testing and nursing homes had previously asked for testing. The fact that 70% of long-term care residents have dementia makes testing particularly important. Dementia makes it difficult to diagnose COVID-19, given that diagnosis often relies on the individual to report their symptoms. Furthermore, frail adults often have atypical symptoms, such as a lack of cough or fever.
Masks, which must now be worn whenever care is provided (as of April 10), were previously only worn when treating symptomatic residents. Governments across the country were shamefully slow at ensuring that health care workers (and those in long-term care in particular) were adequately protected. For example, as recently as March 30, Ontario’s Chief Medical Officer insisted that personal support workers at long-term care facilities did not need to wear protective equipment unless their location was the site of an outbreak. Some also argue that Alberta was slow to prohibit staff from working in multiple long-term care facilities. For example, the infection at BC’s hardest hit home (with 20 deaths) was caused by a staff member who worked at more than one site. While BC banned individuals from working at multiple facilities on March 27, Alberta did not follow suit until April 10.
Although it is tempting to conclude that the Alberta government did not act quickly and decisively enough, it is important to note that some of these rules involve complex trade-offs. For example, limiting visitors has psychological consequences for residents and prohibiting staff from working multiple jobs may result in some facilities being understaffed, which affects the care received by residents. However, it is less clear why the government delayed testing asymptomatic residents and providing workers with adequate protective equipment for so long.
Hindsight aside, the government must not squander this learning opportunity to rethink infection control now that they have been tested by a pandemic. For example, policy-makers should critically evaluate their infection control protocols to guard against future COVID-19 outbreaks or the spread of other illnesses that those in long-term care are susceptible to, such as influenza. Furthermore, governments must take this opportunity to develop a pandemic plan for the long-term care sector by reflecting on what worked, what didn’t, and what infection control measures should have been implemented sooner. Policy-makers focused a great deal of attention on preparing hospitals for a surge in demand, but it is now clear that they should have devoted at least as much time and attention to preparing long-term care homes to manage the pandemic.
Systemic Problems in Long-Term Care
Although it might be tempting for policy-makers to dismiss the long-term care crisis as a product of the COVID-19 pandemic, this is short-sighted. In fact, experts have been sounding the alarm on deep systemic concerns with long-term care for years, which the pandemic merely served to expose. Over the past few years, there have been a series of scandals, all of which highlight the persistent problems with long-term care in Canada (see e.g. here, here, here, here).
Chief among these systemic concerns is staffing, given that high turnover and understaffing can lead to poor care or even neglect. During the COVID-19 outbreak, high rates of staff infections and the struggle to access personal protective equipment have illuminated concerns with the vulnerability of long-term care staff. In addition to jeopardizing their physical health, the working conditions that many staff have endured during COVID-19 will also undoubtedly affect their psychological health.
Many personal support workers or health care aides working in long-term care are immigrants, most are women, and they are underpaid relative to their hospital counterparts. The precarious and sometimes dangerous nature of their employment may make them less able to advocate for their own safety in long-term care homes or to push back against dangerously low levels of staffing. Many personal support workers and health care aides are employed part-time and thus may not have access to sick leave benefits, which incentivizes working while ill to make ends meet. Furthermore, many of these workers piece together shifts at different facilities, in some cases because full-time hours would entitle them to benefits that employers do not wish to pay. Poor compensation and difficult working conditions contribute to problems with worker recruitment and retention which, in turn, negatively affect resident care. As McCoy and Lightman argue, governments have made a “critical mistake” in “devaluing…labour connected to care” and its “austerity programs have “placed workers in vulnerable positions.”
A related systemic quality of care concern results from the ownership status of long-term care facilities, which may be public, non-profit, or for-profit. Although it is not yet clear what the data from COVID-19 will show about the connection between infection and fatality rates and facility ownership, governments should pay close attention to this information once it is available.
However, it is notable that BC’s and Alberta’s hardest hit homes, 4 out of the 5 Ontario facilities with the most deaths, and the Montreal facility that is under investigation are all for-profit. There is a sizeable body of evidence indicating that the quality of care in for-profit facilities is inferior to that delivered by public and non-profit facilities. This is due to a conflict of interest between profit and investing in things that improve quality of care, such as staff (see e.g. here, here, here, here).
Concerningly, a recent review of Alberta Health Services might lead to the privatization of the long-term care sector. Specifically, this report recommended that AHS reconsider “facility ownership in cases where private delivery may be more efficient and appropriate.” COVID-19 has given the government the opportunity to reform the long-term care sector in a manner that improves quality of care and privatizing facilities would be a step in the wrong direction.
Conclusion
The only thing that could further exacerbate the tragic effects of COVID-19 on Canadian long-term care residents is if governments fail to seize this opportunity to make long-overdue changes to the long-term care sector. This certainly includes the provinces, but there is also a potential opportunity for the federal government to take greater leadership in this sector. For example, governments must address the wages and working conditions of staff, in order to improve the retention of workers. Given chronic understaffing in these facilities, better retention will in turn improve the quality and continuity of care received by residents. Governments must also re-evaluate both their usual infection control measures, along with those that should be implemented during a disease outbreak. Finally, although privatization can be tempting in difficult fiscal times, given that the sale of facilities can generate capital, this would be a step backwards in terms of quality of care. If anything, governments should further invest in the public sector—home care in particular—to help avoid housing people in institutional settings altogether.
This post may be cited as: Lorian Hardcastle, “The Tragic Effects of COVID-19 in the Long-Term Care Sector” (April 20, 2020), online: ABlawg, http://ablawg.ca/wp-content/uploads/2018/07/Blog_LH_LongTermCare.pdf
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