Revera report brings relief to grieving daughter, but she wanted to be involved

An internal review by the company that manages Forest Heights Long-Term Care Home in Kitchener has relieved some of the guilt felt by one grieving daughter but should have involved loved ones of those who died, she says.

'We kind of forgot about long-term care,' said review chair Dr. Bob Bell

A masked resident of Forest Heights, in Kitchener, Ont., leaves the long-term care home in ambulance on April 28, 2020. On Monday, the company that runs the long-term care home released an internal review of operations during the first wave of the pandemic. (Evan Mitsui/CBC)

An internal review by the company that manages Forest Heights Long-Term Care Home in Kitchener has relieved some of the guilt felt by one grieving woman who was like a daughter to a resident, but she says the review should have involved loved ones of those who died. 

The Revera Pandemic Report: A Perfect Storm, released Monday, was undertaken by an external advisory panel, made up mostly of doctors and experts in the medical field who volunteered their time.

While the company operates 74 long-term care homes across the country and 96 retirement residences, the outbreak at Forest Heights Long-Term Care Home in Kitchener stood out. It had the sad distinction of being the longest-running outbreak in the Revera network to date, and by its end had killed 51 residents.

One of those residents was Shirley Egerdeen. Egerdeen never had children of her own, but Tracy Rowley became the next-best thing.

"I think it was time that they acknowledged that they had a problem," Rowley told CBC News. "As a person who lost a family member, knowing that no one had taken responsibility was always an issue."

Egerdeen died April 22, the fourth Forest Heights resident to die that day, says Rowley, who has joined a class action lawsuit against Revera.

Shirley Egerdeen was like a mother to Tracy Rowley. The two celebrated their birthdays together every year, she said. (Submitted by Tracy Rowley)

"It helps with the guilt you already felt, putting your parent into a home," she said.

The report recommended surveillance testing for all long-term care homes and retirement residences in Canada. That's already begun in Ontario — but depends on where a community stands in the province's colour-coded framework.

Root causes

Panel chair Dr. Bob Bell says there were really three root causes that led to major problems at Revera's long-term care homes and retirement residences across the country:

  • Chronic under-spending on long-term care.
  • How Canada prepared for the pandemic.
  • How little was known about asymptomatic spread.

In the early days of the pandemic, Ontario and Canada looked to places like Italy and New York for guidance on how to respond to COVID-19, Bell told CBC Kitchener-Waterloo.

In those places, hospitals were catastrophically overwhelmed and so we prepared to prevent the same, said Bell.

"We wanted to protect our hospitals, we wanted to make sure that we had personal protective equipment in the hospitals — masks and gowns and gloves and reagents to test for the virus," Bell said. "We kind of forgot about long-term care."

"We left it out in the open, despite knowing that some of the most vulnerable, chronically-ill people in society live in those nursing home residences."

The Revera Pandemic Report says the following about how a lack of access to PPE affected the spread of COVID-19:

"On April 8, the Public Health Agency of Canada issued a recommendation that all staff working in long term care settings be universally masking as well. However, earlier decisions to prioritize the protection of in-hospital staff would prove disastrous for long-term care and retirement residences, which generally only keep a three-day PPE supply on hand as the pandemic preparedness legislation requires.

... While universal masking became mandatory in Ontario long-term care homes on April 8, the actual same-day delivery of PPE to long-term care homes did not take effect until April 13, five days later. By then, COVID-19 had gained a strong and stubborn foothold in long-term care homes across the country.

Revera's data shows that 97 per cent of its residents' infections — or 844 of its 873 cases in long-term care, which was much more severely impacted than the company's retirement residences — could be traced back to outbreaks that occurred during the week of April 13 or earlier. The same timeline applies to 90 per cent of infections among its staff."

Family members left out

Despite the critical eye provided by the expert advisory panel, Rowley would have liked to see family members, like her, involved in the review.

"At least to be heard," she said. "There's a difference between what the government or the home owners feel that they need ... and what a family and their expectations are."

Rowley says the last time she communicated with Revera was when she went to pick up Egerdeen's belongings for donation. She says she was never asked for feedback by the long-term care home — a conversation she said she would have engaged in. 

"I never got that phone call that said: 'Hey, you know what, what do you think we could have done better to help your mother? Is there something you feel we might have missed with your mother?' I got nothing like that."

In its final paragraphs, the review says while it has taken a look at the factors that led to the deadly first wave of COVID-19 in Revera's long-term care homes specifically, it also said it cannot answer the question of why the needs of 500,000 of the country's seniors weren't more of a priory leading up to and during the first wave of the pandemic. 

With files from Paula Duhatschek and Kate Bueckert