Orderlies worked without PPE, COVID-19 patients wandered Herron's halls for days after health agency took over

Emails obtained by CBC News indicate CHSLD Herron remained critically short-staffed after it was put into trusteeship, but the regional health agency did not take steps to fix the problem until April 8 — a week and a half after it took over.

Documents show CIUSSS Ouest-de-l'Île-de-Montréal slow to act after takeover, as dozens more residents died

Lori Morrison and her husband, Greg Giroux, hold up a signs outside CHSLD Herron on April 11, the day the provincial government revealed that 31 residents had died at the private long-term care home in Dorval, Que., since late March. (Graham Hughes/The Canadian Press)

On April 4, Trisha went back to work at the Résidence CHSLD Herron in Dorval, in Montreal's West Island — her first shift in more than a week.

What she saw surprised her. Many of the residents she used to care for were gone. Their beds were empty.

"I was so scared," said Trisha. "Where are all these people? I asked the person in charge. He said, 'They are not all dead.' He could not give me an answer."

Trisha, whose true identity CBC has agreed to conceal out of concern for professional repercussions, described chaos at the Herron, nearly one week after the home — a private, unsubsidized long-term care residence — was put under provincial trusteeship.

Trisha is one of nine staff members at the Herron with whom CBC spoke in recent days. All worked in the home after its daily operations were taken over by the regional health agency, the CIUSSS de l'Ouest-de-l'Île-de-Montréal

They describe working without appropriate protective equipment, not knowing which residents had tested positive for COVID-19, and being so short-staffed on some shifts that they weren't able to meet the basic needs of the 130 residents.

Records from the owners of CHSLD Herron indicate that, of the 31 residents known to have died at the home since the start of the pandemic, 28 of them died under the watch of the regional health agency.

Emails obtained by CBC News indicate the CIUSSS was aware the Herron remained critically short-staffed after it was taken into trusteeship, but it did not fix the problem until April 8 — a week and a half after it took over.

The Herron's owners, Samir Chowieri and his daughters Katherine, Tanya and Samantha Chowieri, whose company is called Groupe Katasa, contend they went to the regional health agency seeking help — and that the CIUSSS made a bad situation worse.

What follows is an account of what has happened inside the Herron from the point the administrators sought help, based on interviews with nine people who work or have worked there and documents obtained by CBC News.

Patient Zero

A sick resident is trundled out of CHSLD Herron to be taken to hospital on April 11. (Graham Hughes/The Canadian Press)

Until March 27, CHSLD Herron was frequently understaffed, but it was functioning, staff said.

On that date, the first Herron resident tested positive for COVID-19. He was taken to hospital and later died.

Nurses were getting sick, too: six out of the seven registered nurses on staff were experiencing COVID symptoms, and of seven licensed practical nurses (LPNs), only four were still healthy.

By Herron's own admission, it did not have appropriate personal protection equipment for staff. An email correspondence between Samantha Chowieri and the CIUSSS shows that Chowieri requested PPE from the regional health agency on March 23 but was denied.

By March 28, three more LPNs had fallen sick and went home — leaving just one LPN standing.

About a quarter of the orderlies (préposés aux bénéficiares, or patient attendants) had also stopped working — either because they were experiencing COVID symptoms or because they felt it was no longer safe to work at CHSLD Herron.

Within weeks, a quarter of those patient attendants would test positive for COVID-19.

Asking for help

Quebec Health Minister Danielle McCann, left, seen here with Premier François Legault, right, and Horacio Arruda, director of public health, said Friday she believes the CIUSSS 'has done everything it could,' and she awaits the outcome of investigations into what happened at CHSLD Herron. (Jacques Boissinot/The Canadian Press)

In a news conference held on April 11, Premier François Legault accused staff of "abandoning" the Herron and its residents.

Not true, according to Groupe Katasa documents: most of the absent staff were either waiting to be tested or already sick.

On March 29, Samantha Chowieri texted Brigitte Auger, the associate director of long-term care at the CIUSSS. She had run out of LPNs, or auxiliary nurses.

"We have no more auxiliary nurses available tonight. Please call me because we're no longer able to give the necessary services. None of the agencies want to come," read the text.

At 2:49 p.m., Auger wrote back.

"Hello, on conference call with the ministry. I got your email, any employees came in?"

Chowieri responded: "We need support, do you have other means we can use to help?"

At 4:29 p.m., Auger replied that a doctor and a nurse were on their way to help. Later, she texted again to say that she had found a nurse and an orderly, or patient attendant, to assist them.

By all accounts, what those replacement health-care workers found inside the home was abhorrent.

Bedridden residents were lying in sheets stained brown up to their necks in excrement, so long had it been since their diapers had been changed. Some were dehydrated and unfed.

"The conditions were disgusting. The patients were drenched in urine and feces," said Loredana Mule, a replacement nurse who worked that evening. "It was quite appalling."

The head of professional services at the CIUSSS, Dr. Nadine Larente, is the doctor who went to help. She told the French-language newspaper La Presse the place was in chaos: one LPN and two patient attendants were trying to care for 130 residents. Food trays had been placed on the floor, dishes untouched because residents with mobility issues couldn't reach them.

Larente called home and enlisted her husband and teenage children to come help feed everyone.

At the end of that shift, the last remaining LPN on Herron's staff went home and never came back.

That night, one Herron resident died in hospital. A second died in the home. The CIUSSS put CHSLD Herron under trusteeship.

No improvement in staffing levels

Health-care workers can be seen tending to residents at CHSLD Herron on April 13, more than two weeks after the regional health authority put the long-term residence under trusteeship. Patient attendants said in the week after the authority took over, they worked without personal protective equipment even as the coronavirus spread like wildfire. (Ryan Remiorz/The Canadian Press)

The same night, shortly after midnight on March 30, CHSLD Herron's co-owner Samantha Chowieri sent an email to residents' families.

"You can rest assured that all residents and employees that came into contact with these affected people were put into preventative isolation. Also, as a safety measure, all residents are confined to their rooms and we are monitoring all of them closely by visiting their rooms regularly," it read.

"Due to many staff members being put into preventative measures, and some testing positive, we have been with reduced staff since this morning. We have contacted the CIUSSS for support and finally have received response to our request this evening."

"The CIUSSS is on site working with the CHSLD Herron team in order to recuperate all normal services. We're hoping to get our regular staff back on the floors quickly."

The letter gave no hint of just how seriously short-staffed the Herron was. Nor did that situation change after March 30, with the institution now under CIUSSS trusteeship.

Staff work schedules, supplied by the home to the CIUSSS and obtained by CBC, show daily shortages. A spokesperson for Herron's owners says the CIUSSS was sending contacts for agencies where the home might find more staff, but there were never enough workers available.

CBC News spoke to four patient attendants who worked in the week that followed Herron being put under trusteeship. Their identities are being withheld, because they fear for their jobs.

Between March 30 and April 8, there were only three patient attendants working on a shift, they said. For an institution of that size, there should have been 22 patient attendants on a day shift, 16 through the evening, and another five attendants overnight.

No "hot zone" for infected patients was established — and residents known to have tested positive for COVID-19 were wandering around the floor.

"I was totally shocked," said one patient attendant. Asked if she'd ever seen anything like it, she said," Never. Never. Never."

One attendant described working from 3:30 p.m. until 7:30 a.m., to tend to the needs of the dozens of seniors on the floor. More than one attendant described patients who were still dehydrated, hungry, and unchanged.

One went to change the diaper of a man who had obviously not been cared for in many hours.

"It seems like he [had defecated] more than one time. The air — I couldn't even breathe," she said.

On April 5, one patient attendant walked out and decided she could not return. She said it was a difficult decision, but she works in more than one long-term care home. She said she didn't have the appropriate PPE at the Herron, and she could not risk carrying the virus to her other jobs.

It's not clear why the regional health agency didn't mobilize more staff earlier.

On April 8, several public health nurses were sent to the home.

One describes walking into an unfamiliar facility with no training and immediately having to call a time of death of a resident who had died overnight.

"Wednesday was tough," she told CBC News. "Wednesday was really tough, but I think that's because we were three nurses caring for 150 patients."

The legal machinations

A man unloads supplies at CHSLD Herron on April 13, while a funeral services vehicle is parked in the foreground. Thirty-one residents are confirmed to have died since late March. (Ryan Remiorz/The Canadian Press)

In an email dated April 4, Samantha Chowieri wrote to management at the CIUSSS.

"We want to co-operate as much as possible. A meeting is necessary to clarify certain points," she said.

Instead, Herron's owners received two legal notices: one on April 5, and the other, on April 8.

"We are informed that the situation has not improved in any way," reads the second notice.

"As such, I order the CIUSSS West Island to mobilize the necessary orders to ensure services at Herron House."

The legal notice also asks Groupe Katasa to give its staff list to the CIUSSS, even though email correspondence sent to CBC News indicates the agency already had that list in its possession.

The notice also asked for patient information, even though staff working inside the establishment say the patient's charts and contact information for next of kin were easily accessible on each floor.

It's unclear why the CIUSSS asked for information it was already given, and the CIUSSS has declined to comment.

In a hastily arranged news conference outside the Lakeshore Hospital on April 11, the regional health agency's president and CEO, Lynne McVey, said the CIUSSS was invoking Section 106 of the provincial Public Health Act and taking over the home.

That section gives public health authorities the power to take any measure necessary to deal with a threat to the health of the population.

It's not clear, however, why the CIUSSS waited 10 days before it took that step, nor why it sent two legal notices — not required by law — before it did that. CBC News put that question to the CIUSSS, which did not respond.

Groupe Katasa denies being 'unco-operative'

A woman prays in front of Résidence CHSLD Herron on April 13 in Dorval, in Montreal's West Island. (Ryan Remiorz/The Canadian Press)

On April 11, the same day that McVey met reporters on the lawn outside Lakeshore General Hospital, and nearly two weeks after the CIUSSS put the Herron under trusteeship, Premier Legault cancelled a planned day off to announce, ashen-faced, that 31 people had died in the home since March 13.

Legault said the reason why it took so long to determine the number of deaths was because the Herron's owners were "unco-operative."

He said there would be police and public health investigations into what happened. Later the same day, Quebec's coroner announced it would also investigate.

Soon after, Groupe Katasa sent a letter to Legault's office, outlining all the ways the Herron's owners say the CIUSSS erred. Co-owner Katherine Chowieri said the regional health agency hadn't supplied appropriate protection equipment to staff, and no "hot zones" had been created in the home.

She said Katasa had emailed the home's schedules to the CIUSSS in advance, and the CIUSSS had refused to meet them, "instead deciding to retain legal services to send us two cease and desist letters asking us to give them information we had been giving them on a daily basis."

She said once the CIUSSS put the home in trusteeship, staff weren't told which residents had tested positive for COVID-19, putting them all at risk.

Flowers, plush toys and notes adorn the lawn in front of CHSLD Herron — in tribute to residents who have died at the home.

CBC News tried to put all of these allegations to the CIUSSS, but it declined to respond to them.

In a statement, the regional health agency said it was not until the evening of April 10 that it obtained the information that 31 people died.

"We were transparent, based on the information we had," it said.

The statement said the situation has stabilized and is improving, and all residents at Herron have now been tested for COVID-19.

"I think the CIUSSS has done everything it could to provide the care at the CHSLD Herron," said Danielle McCann, Quebec Minister of Health, on Friday. "What's important is to wait for the result of the investigation."

The public health nurse sent to work at CHSLD Herron on April 8 continues to work there, and she agrees the situation has improved.

She says in the days since the home has gained notoriety in the media, the phone rings off the hook. Nurses and attendants pick it up. They're greeted by strangers, calling them murderers and killers.


Kate McKenna is a senior reporter with CBC News. She is based in the parliamentary bureau.

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