The Ministry of Long-Term Care’s oversight mechanisms “largely collapsed” when the COVID-19 pandemic hit, with on-site inspections of long-term care homes grinding to a halt for nearly two months during the first wave of the pandemic, according to an investigation by Ontario’s ombudsman.
The report by Ontario Ombudsman Paul Dubé, which was released Thursday, focuses on the Ministry of Long-Term Care’s inspections-related activity at homes during the initial stages of the pandemic. It found that over a seven-week period during the initial wave of the pandemic, the ministry’s inspections branch “simply stopped conducting on-site inspections.”
In Hamilton, no on-site inspections occurred for three straight months.
“What we uncovered was an oversight system that was strained before the pandemic, and proved to be wholly incapable and unprepared to handle the additional stresses posed by COVID-19,” the report read.
In one case reviewed by the ombudsman’s office, one man complained to the Ministry four times between April 6 and May 5, 2020 about “disturbing conditions” in his mother’s long-term care home.
“None of his concerns were inspected until October 2020, many months after his mother had already died from COVID. In total, 53 residents died at that same long-term care home during the first wave,” the report continued.
In April 2020, the report notes, a woman complained to the ministry about the conditions at her parents’ long-term care home, indicating that it was “severely” short-staffed and residents were not being cleaned, fed, or given their medications. One of the woman’s parents had died of COVID-19 and the other was sick with the virus, the report read.
“A Ministry inspector ‘reassured’ (the woman) over the phone and then closed the file without taking any action. Thirty-three residents died at that long-term care home during the first wave,” the report continued.
“It’s impossible to know what might have happened if the Ministry inspectors had diligently followed up on complaints… when they were received.”
Inspections, the report said, were not carried out as the Ministry had “no plan for inspectors to safely continue their work during the pandemic.”
“The (Inspections) Branch did not have a supply of personal protective equipment, and inspectors were not trained on infection prevention and control. Once inspections resumed, and for much of the first wave, only inspectors who volunteered were sent to homes experiencing COVID outbreaks,” the report read.
“Consequently, some areas of the province had as few as three or four inspectors to conduct on-site work, when there would normally be 20 to 25.”
Instead of on-site inspections, the branch “monitored and supported” homes by making “periodic” telephone calls to the facilities.
Ontario has more than 600 long-term care homes, comprising of nearly 80,000 resident beds.
There were close to 2,000 COVID-related deaths in the long-term care sector during the first wave of the pandemic, which occurred between January 15, 2020 until August 2, 2020.
“Much more needs to be done to address the serious lapses in oversight I have detailed in this report,” Dubé wrote.
In the report, the ombudsman made 76 recommendations, all of which have been accepted by the ministry.
Some of the recommendations include ensuring inspectors are always available to do on-site inspections, clarifying when off-site inspections are appropriate during any future pandemic or other type of emergency, and ensuring the ministry brief its inspectors on emerging threats.
According to the Ombudsman’s Office, the Ministry has agreed to report back every six months on its progress in implementing the recommendations.
“The next pandemic could come sooner than we think and be even deadlier than the COVID-19 pandemic,” the report read.
“Effective preparedness and strong oversight are absolutely essential to mitigating risk.”