The Quebec Ombudsman has submitted his final report on what went wrong in the province’s long-term care homes during the first wave of the pandemic, saying residents were “put aside” and begging the government to right its wrongs by immediately making the recommended changes.
Marie Rinfret says she is asking Quebec Health Minister Christian Dubé to provide her with ongoing updates on progress, starting this spring, until the 27 recommendations in her report are implemented. artwork.
Rinfret’s investigation is separate from the Quebec Coroner’s inquest into the number of pandemic-related deaths in retirement homes and the impact of the pandemic on the sector as a whole – although the two share the same ‘goal of finding out what went wrong and identifying what needs to change.
Rinfret released an interim report last fall in which she identified major issues in government pandemic planning, noting that the province’s long-term care facilities – commonly known by their French abbreviation CHSLD – were a “blind spot”.
Most of the 3,890 deaths in Quebec in the first wave were among residents of CHSLDs, while staff watched helplessly, fled the overwhelming conditions or were themselves ill with the virus.
In his final report released Tuesday afternoon, Rinfret concluded that long-term care workers “have suffered the brunt of the inaction of public authorities.”
These workers accounted for 25% of COVID-19 cases at the time and 11 died.
Officials knew how under-resourced long-term care homes were before the pandemic, Rinfret said, but failed to act on the first wave. She also highlighted the fact that homes should provide similar services to hospitals, despite the lack of expertise and staff to do so.
Meanwhile, hospital resources have been strengthened. The document details how Quebec officials were distracted by the disaster in European hospitals, especially in Italy, and believed those in the province would also be besieged by the virus.
Staff and personal protective equipment moved to hospitals, but the kind of patient flare they expected never happened. At the same time, hundreds of elderly people were dying in long-term care facilities.
The gravity of the situation flew under the radar
Authorities have largely underestimated what would happen if the virus entered institutions, where Quebec’s most vulnerable live, Rinfret said.
A lack of “real-time data on the health system as a whole” meant the seriousness of the situation went unnoticed.
“While Quebec’s eyes were on Italy, no risk analysis adapted to Quebec’s residential-resource model and its specificities was carried out,” wrote Rinfret. “This is how the CHSLDs slipped through the cracks of any scenario.
The report also paints a picture of the results of this lack of foresight.
It describes how personal protective equipment was not distributed adequately, how staff moving from facility to facility contributed to the rapid spread of the virus, and how basic hygiene care , diet and hydration were postponed or canceled.
“The exclusion of informal caregivers has taken a heavy toll on the mental and physical health of residents,” reads a summary of the report.
The document builds on the interim report, which also described widespread institutional failures.
It enumerated an understaffed, insufficiently trained and under-equipped staff, residents deprived of care and dying alone, and a planning process that simply did not take into account the reality on the ground of the CHSLDs, which were being pushed to the end. extreme even before the pandemic started.
The final report is based on interviews and 1,355 testimonies from CHSLD residents and members of their families, CHSLD employees, managers of health authorities and family caregivers. Rinfret wrote that his investigation did not seek to lay blame, but to help avert such a disaster in the future.
Among the recommendations, Rinfret calls on the government to create:
- A long-term care risk assessment and management policy.
- A detailed plan to strengthen the capacity of residences to apply infection prevention and control measures.
- A procurement strategy for personal protective equipment.
- A deployment plan for emergency personnel within the health network.
- Protocols with professional orders, federations and associations, unions and educational institutions for the deployment of additional staff in exceptional circumstances.
- A national strategy to fight against staff shortages and promote trades and professions in health and social services.
- A plan of action to recognize the complexity of providing care and services in long-term care homes.
Government officials are expected to respond to Rinfret’s report later this afternoon.