KAWARTHA LAKES-Kawartha 411 News has learned Pinecrest Nursing Home in Bobcaygeon waited several days to report the 2020 Coronavirus outbreak to the local Health Unit and was later ordered to retrain all staff on infection prevention and control just months after 28 residents died from the virus.
An outbreak was declared at Pinecrest on March 18, 2020. In all 28 of the nursing homes 65 residents died. At least two dozen staff tested positive. Four other members of the community died as well, including Jean Pollock, the wife of Ted Pollock, a resident of Pinecrest who also died after contracting the virus. Read more here:https://www.kawartha411.ca/2020/03/28/wife-of-pinecrest-nursing-home-resident-dies-of-coronavirus/
A Ministry of Health and Long Term Care inspection done from June 8-11, 2020 found there were at least eight residents who were exhibiting Coronavirus symptoms a number of days before they were placed in isolation and before the suspected outbreak was reported to the Haliburton Kawartha Pine Ridge District Health Unit in March.
The inspection was done following an anonymous complaint regarding concerns with the homes infection, prevention and control (IPAC) practices.
According to the Ministry, Pinecrest failed to ensure that staff monitor symptoms of infection in residents on every shift in accordance with “evidence-based practices and in accordance with prevailing practices and staff on every shift record symptoms of infection in residents and take immediate action as required”.
According to the report, the Director of Care (DOC) and an RN both confirmed they did not use the Sample Respiratory Outbreak Line Listing Form for daily monitoring of infections and were not aware that this tool was to be used for daily surveillance of infections. The RN indicated they only utilized that tool on a monthly basis to track all infections in the home. The monthly tracking tool was apparently not provided.
Inspectors reviewed the licensees Infection Prevention and Control (IPAC) policy (reviewed July 2019),which indicated under the procedure for managing outbreaks, early recognition of a potential problem was to be aided via the use of the 24 hours report book, use of the short-term illness monitoring sheet and progress notes. The DOC or designate was to notify the Medical Advisor physician and Health Unit of clustering of cases, which did not happen according to the Ministry.
One resident was admitted to the home on a specified date, developed symptoms a number of days after their admission and was not placed on isolation until the following day. Two days later, the resident was tested and diagnosis was confirmed.
One resident was on contact/droplet precautions after returning from the hospital and was placed in a room with another resident even though there were a number of empty rooms available and should have been placed in a separate room.
Another resident developed COVID symptoms but it was not identified on the line listing in the report book until a week later.
By the time Public Health was notified of a suspected outbreak and an outbreak declared in Mid March, a number of residents already had symptoms of infection according to the Ministry.
During an interview with the DOC they told inspectors they were not in the home until the day before the outbreak was declared stated the report. The DOC confirmed that no short-term illness form was put in place until a number of days later, when the Public Health (PH) was notified of a suspected respiratory outbreak. The DOC was also not aware that specified residents who were exhibiting symptoms of infection, were also not immediately placed on isolation and should have been according to the report.
“The licensee failed to ensure that the staff monitored and recorded symptoms of infection in residents on every shift in accordance with evidence-based practices and/or in accordance with prevailing practices (utilizing the respiratory outbreak line listing) and that staff took immediate actions as required as residents were not immediately placed on isolation, the ICP was not informed and the PH was not immediately notified of a suspected outbreak.”
Even after an outbreak was declared, the health unit did not warn the community about the seriousness until a local doctor revealed there were many more cases of COVid than those being reported. Read more here:Â https://www.kawartha411.ca/2020/03/22/lindsay-doctor-says-actual-number-of-people-infected-with-coronavirus-at-bobcaygeon-nursing-home-probably-more-than-30/
The outbreak was declared over on May 14, 2020 but the Ministry alleges that even after the death of 28 residents, infection and prevention control measures were still not adhered to in some cases.
At the time of the inspection (June 2020), the home still had a number of residents on droplet/contact precautions in a number of resident rooms. Despite this officials say some staff were not practising physical distancing nor were they wearing masks.
The report states: on a specified date, two staff were observed sitting outside the home under a gazebo, within two feet of one another and not maintaining the required 6- foot distance from each other or wearing masks. Later the same day, two staff were observed sitting in a car together in the parking lot, both in the front seat and not physical distancing or wearing a mask.
Residents were also observed sitting in the lounge in their wheelchairs, within three feet of each other and neither resident was wearing a mask according to the report.
Kawartha 411 first reported on these issues on March 24, 2020. Read more here:https://www.kawartha411.ca/2020/03/24/questionable-containment-protocols-at-bobcaygeon-nursing-home-at-the-centre-of-local-coronavirus-outbreak/
A PSW was observed wearing the same pair of gloves throughout the home, entering and exiting resident rooms without performing hand hygiene/or changing their gloves the report states.
According to the inspection report, a member of the management team was observed walking throughout the home, frequently touching the front of their mask and was observed moving their mask down from their nose while talking to staff members at the nursing station.
The inspector said they observed that two housekeepers were scheduled to work each day and two were observed cleaning resident bedrooms, dining room and activity room, but not the tub rooms or staff room. The schedule did not include cleaning and disinfection of surfaces in their high traffic areas such as the tub/shower room, staff lunchroom, locker room and washroom and boardroom (used by many staff according to report). The Administrator reported that the schedule was temporary until they had time to amend and re-organize the housekeeping routines and schedules.
“The licensee did not ensure that adequate housekeeping staff were available in the home to complete the required cleaning and disinfection of environmental surfaces before and during their outbreak.”
The report found that during the outbreak, the Administrator stated that the extent and seriousness of the outbreak was not anticipated, the situation became overwhelming and many of the health care and environmental services staff became ill and there was no backup staff available to call upon. The Administrator stated that on some days they had only one housekeeper until external services were able to offer assistance.
As a result of the inspection, Pinecrest was ordered to take the following steps.
Specifically, the licensee shall:
1. Review and revise the existing IPAC policies to ensure they meet best- practice guidelines (as per PIDAC and Ministry guidelines) related to surveillance, monitoring of IPAC practices in the home, access to PPE and hand sanitizer and cohorting of residents.
2. Retrain all staff on proper hand hygiene practices, donning and doffing of PPE, visitor screening PPE requirements, surveillance, physical distancing requirements of residents and staff, self-isolation practices for any residents newly admitted or returning from hospital and proper placement of PPE stations. A documented record is to be kept of the training of all staff.
3. Develop and implement a monitoring process to ensure compliance of all staff with the IPAC program, including practices of proper hand hygiene, physical distancing of residents and staff, both inside and outside of the home, screening of visitors and proper donning/doffing of PPE.
The report says the severity was a level 4 as “immediate harm was identified”. The scope was level 3, widespread, as the infection prevention and control program affects all residents and staff according to the Ministry. Read the full report here:Â http://publicreporting.ltchomes.net/en-ca/File.aspx?RecID=25579&FacilityID=20393
We have contacted officials at Pinecrest for comment but have had no response.
The home had non-compliance issues in the past with a Voluntary Plan of Correction (VPC) was issued to O.Reg. 79/10, s. 229(4) on May 16, 2018 during inspection #2018_716554_0007. (111). Read that report here:Â http://publicreporting.ltchomes.net/en-ca/File.aspx?RecID=20727&FacilityID=20393
It’s unclear if any other measures such as fines were levied or disciplinary measures taken.
