Maples care home not prepared for 'precipitous' loss in staff during crisis in November, report says

A Winnipeg care home where ambulances were called as residents lay dying amid a COVID-19 outbreak in November was not adequately prepared for staff shortages during the pandemic, an external reviewer says.

Some staff brought in during outbreak's first 10 days weren't trained for the job, external probe finds

The outside of the Maples Long Term Care Home is pictured in this file photo. An investigation into the facility was started after paramedics were called to care for residents in November. (Lyzaville Sale/CBC)

A Winnipeg care home where ambulances were called as residents lay dying amid a COVID-19 outbreak in November was not adequately prepared for staff shortages during the pandemic, an external reviewer says.

While there were pandemic plans in place at the Maples Long Term Care Home, the site was not ready for the "precipitous and significant loss of staff over a very short window of time" when many workers were forced to self-isolate because of COVID-19 exposures, Dr. Lynn Stevenson said at a news conference on Thursday.

Stevenson's external review makes 17 recommendations for the Revera-owned care home, the Winnipeg Regional Health Authority, and for Manitoba's health incident command structure and health department.

Four of those recommendations are listed as additional considerations, which include rebuilding trust with families who spoke of inconsistent communication during the outbreak, as well as supporting staff who were negatively impacted by the experience.

WATCH | External review released of Maples Long Term Care Home: 

External review says Manitoba health officials didn't grasp urgency of Maples care home situation

1 year ago
Duration 3:22
A Winnipeg care home where ambulances were called as residents lay dying amid a COVID-19 outbreak in November was not adequately prepared for staff shortages during the pandemic, an external reviewer says.

"I heard very clearly from many families that their trust had been eroded at Maples," said Stevenson, a former associate deputy minister of British Columbia Health, adding she spoke to 38 such families.

"[Staff] have worked not only enormously hard from a physical point of view, but emotionally it's been very difficult.… These are their families. They care for these people, so they have experienced enormous loss."

The report notes that some of its recommendations have already been completed, though most are still listed as underway or not started.

Manitoba Health Minister Heather Stefanson said the province is establishing an implementation team, which will create a plan to carry out the report's remaining recommendations. That plan will be made public within 30 days, she said.

A spokesperson for Revera, the for-profit company that runs the care home, said it plans to work with the province and the Winnipeg Regional Health Authority to implement the report's recommendations.

The external review was called following the night of Nov. 6, when paramedics were called to the facility to care for a dozen rapidly deteriorating residents.

The scene outside the Maples Long Term Care Home is pictured in this file photo taken on Saturday, Nov. 7, 2020. (Walther Bernal/CBC)

When ambulances arrived, two residents receiving end-of-life care had died, including one who had COVID-19, officials previously said. Another three residents were taken to hospital, including one in critical condition. The next day, health officials said eight people had died at the 200-bed care home in the previous 48 hours.

Eddie Calisto-Tavares, whose father died at the care home on Nov. 11, said the report doesn't go far enough to hold the province accountable for what happened.

"This government should be ashamed of themselves," she said at a news conference later Thursday. "There was no plan. There was no staffing."

Untrained workers, staff shortages

The report says some staff brought into the care home during the first 10 days of the outbreak were not trained to do their jobs.

"These general labourers were not skilled to provide resident care. Resident care managers were assigned to support resident care, but as they became ill, this was not a viable strategy," the report says.

The untrained workers had been brought in by Revera to help with companionship, personal protective equipment auditing, supply management, and nutrition and hydration for residents without swallowing issues, the report says.

There was also understaffing at the home — during the Oct. 30 to Nov. 8 period, there were numerous shifts for both nursing and health-care aides where staff was below 70 per cent of normal, according to the report.

According to a provincial policy document, "the staffing shortages at Maples should have triggered a system-wide response involving provincial incident command," staff redeployment and potential emergency orders, the report says. "This did not occur."

The report found the province didn't tell the care home to ramp up staffing in an outbreak, and it wasn't easy to contact the right person when it needed to supplement its staff.

While the care home put out calls for more staff during the outbreak, Stevenson's probe found there was "some confusion regarding staffing requests," including what was needed and how urgent those asks were.

"I don't know why the support was not given until it became urgent," Stevenson said. "It is a little bit like a bush fire. Once it starts going, it really grabs hold."

Based on protocols in place, the care home's staffing shortages should have triggered a system-wide response involving provincial incident command, mandatory redeployment and potential emergency orders, the report says — but that didn't happen.

There were also large numbers of untrained staff in the care home who needed education to be in roles where they could be useful, which added more work for regular staff, the report says.

Province dodging responsibility: Opposition

Days after the initial crisis, the Winnipeg Regional Health Authority said Revera provided "less than accurate" information about how many people were working that night. On Thursday, Stevenson she wasn't aware of that situation and it wasn't included in the report.

The company had said the home was close to fully staffed — but it was later revealed that only seven of the 19 scheduled health-care aides were actually there after 7:30 p.m.

Among the 17 recommendations in the report are calls for the province to implement a "robust" workforce plan for personal care homes and to review funding for PCHs, "to ensure that staffing levels and services provided are appropriate to the complexity of current and future residents."

The report also recommends the province "mandate and fund a provincewide health-care system response for pandemic outbreaks to reduce fragmentation and delays in outbreak response."

The attention focused on the care home came after an anonymous post on the social media platform Reddit detailed the crisis. The writer said they were among the paramedics at the care home that night.

Opposition NDP Leader Wab Kinew said there are several glaring omissions in the "deeply troubling" report, which he said shows the province trying to avoid accountability for the tragedy that unfolded at the care home.

Stefanson stopped short of saying the province accepts responsibility for what happened that night when asked on Thursday. The health minister said she wants to move forward and implement the recommendations of the report.

Manitoba Opposition NDP leader Wab Kinew says the province needs to accept accountability for what happened during the COVID-19 outbreak at the Maples Long Term Care Home. (John Woods/The Canadian Press)

Liberal Leader Dougald Lamont said the report ignores the ways the province "failed to get ready" for such an outbreak.

"The fact that no one is going to be held to account for it is an absolute disgrace," he said.

After the crisis in November, a rapid response team of community paramedics and staff from the Canadian Red Cross were sent to the care home to provide additional support.

The Winnipeg Police Service started a preliminary assessment, but eventually determined there was no need for a full investigation.

The external review into the Maples care home was first announced on Nov. 8.

The nearly three-month-long COVID-19 outbreak at the home quickly became one of Manitoba's deadliest after being declared on Oct. 20.

In total, 157 residents contracted the illness caused by the novel coronavirus and 56 died in connection with the outbreak, which was declared over on Jan. 12, Stefanson said. Seventy-four workers also tested positive for the illness, she said.

Revera has provided slightly different numbers, reporting on Jan. 12 that 55 residents had died, 153 were infected and 62 staff were infected.

WATCH | Full news conference | Feb. 4, 2021:

Manitoba officials give details of Maples care home external review

1 year ago
Duration 47:06
The investigation was called after a November crisis where ambulances were called and several residents died as the facility dealt with a COVID-19 outbreak.