During Hamilton’s deadliest COVID outbreak at Grace Villa, a provincial inspector found nothing out of place
A provincial inspector went into Grace Villa at the height of Hamilton's largest and deadliest COVID outbreak and found nothing amiss - not one correction listed.
The bare-bones report that isn't even three full pages gives no hint of the horrors staff allege were going on inside, including residents lying on bare mattresses soaked with urine, others waiting 30 minutes for help when choking, as well as accusations of preventable deaths from neglect.
The inspection is shining a spotlight on reduced provincial oversight and raising questions about what role it played in long-term care becoming the epicentre of the pandemic.
It really shows the flaws that we have in the current oversight of long-term care," said NDP Leader Andrea Horwath.
We need a complete overhaul and that includes clear lines of accountability," said the Hamilton Centre MPP. Right now it looks like it falls into some black hole and there's nobody actually following in detail what's happening in the homes and ... people die."
What makes the inspection on Dec. 15 even harder to understand is that the very next day the Ministry of Long-Term Care gave Hamilton Health Sciences (HHS) temporary management responsibility of the home at 45 Lockton Cres. on the east Mountain.
The aim was to stabilize the situation in the home," HHS said in a press release Dec. 16.
The ministry provided no answers on how the inspection report dated Dec. 22 could have found nothing in an unstable home, where 234 people became infected with COVID and 44 died between Nov. 25 and Jan. 20.
Long-term-care home inspectors monitor, evaluate and promote the health, safety, quality of care and rights of residents in long-term-care homes by consistently applying the established methodology and principles," ministry spokesperson Mark Nesbitt said in a statement.
It's not even clear what brought the inspector to Grace Villa other than a complaint. Nesbitt cites privacy in refusing to reveal any further details.
Hamilton public health says it met with the ministry on Nov. 27 - two days after the outbreak was declared. Medical officer of health Dr. Elizabeth Richardson described calling in the authorities" to say we need you to look at this home," while pressing throughout the outbreak for Grace Villa to get increased support and guidance.
But there was only one provincial inspection and it came more than two weeks after Richardson says she asked for help.
I find it very odd they were only in on one day," said Jane Meadus, staff lawyer for the Advocacy Centre for the Elderly. Given the allegations that were going on, I'm very surprised."
She also flags that the inspection doesn't list what standards were in question. It simply says home areas were toured, residents were observed, meal service was observed."
We don't know what it was they looked at," she said. To me that's very unusual."
Meadus points out a corporate consultant" was among those interviewed, which also included the executive director, staff from Grace Villa and HHS, as well as residents. But it's not clear if the interviews took place at the home.
If they were calling personal support workers into a room and speaking to them, there would be a fear of them being retaliated against," said Meadus. They should be calling people ... at home."
Overall, Meadus says the inspection shows the issues with complaint-based oversight.
What they're looking at is that specific complaint," says Meadus. They just don't get a fulsome picture."
It also relies on residents or families complaining, which Meadus says they are sometimes hesitant to do - especially when there is often little result.
The ministry, frankly, has no teeth," said Meadus. There's really very little penalties to a home when they are not acting well ... They assign a hospital. But hospitals really don't know a lot about the running of a long-term-care home ... It would be like taking a university professor and putting them in a kindergarten class. Both are teachers, but they have very different skill sets."
What's needed, says the NDP, is the far more comprehensive resident quality inspection (RQI). But the Conservative government scaled back to focus on complaints and critical incidents.
Grace Villa has not had a comprehensive RQI inspection since November 2018.
We know how quickly the situations can deteriorate at these homes," said Horwath. But if you're giving a full inspection at least annually - the bare minimum - some of these systemic problems might be able to be uncovered."
It's significant because Grace Villa is not alone in disturbing allegations of neglect, severe staff shortages and war zone" conditions during COVID outbreaks.
The homes went in poorly prepared," said Meadus. We haven't had proper inspections."
She questions why homes weren't at least inspected during the lull in the summer.
We knew there would be a second wave," said Meadus. We didn't have the inspectors going in and checking things."
The ministry says operators are ultimately responsible for ensuring their homes keep residents safe.
But Meadus argues more accountability than that is needed, especially in light of the Grace Villa inspection that appears to have done nothing to improve a deteriorating situation in an unstable home.
How is it possible that they have an inspection report with no orders?" asked Natalie Mehra, executive director for the Ontario Health Coalition. Obviously, I don't know how that happened but I do know the history of problems with inspections."
Joanna Frketich is a Hamilton-based reporter covering health for The Spectator. Reach her via email: jfrketich@thespec.com