Extendicare was woefully unprepared for Sasks deadliest COVID-19 nursing home outbreak ombudsman

Extendicare was "clearly not ready to manage" the COVID-19 outbreak that killed 39 residents at its Parkside nursing home in Regina, a damning new report has found.

Earlier this year, provincial ombudsman Mary McFadyen announced her office would conduct an independent probe into the circumstances of the devastating two-month outbreak. Health-care unions and the Saskatchewan NDP had called on the provincial government to hold a public inquiry. The province called instead for an ombudsman investigation. 

McFadyen's report laid out eight recommendations, including a call for Extendicare to apologize in writing to the families of residents who died as a result of the outbreak. In all, 42 Parkside residents infected from November 2020 to January 2021 died during the outbreak, 39 of them as a result of COVID-19. The remaining three infected residents died of other causes.

"Parkside was woefully unprepared for the COVID-19 outbreak despite all the corporate-level planning Extendicare did and all the support offered and provided to it by the [Saskatchewan Health] Authority," the report said.

"We found that Parkside was lax in enforcing the public health orders and implementing effective infection prevention and control measures with its staff to ensure that COVID-19 stayed out of the facility or was at least better contained."

Mary McFadyen is Saskatchewan’s ombudsman, an independent role. (CBC)

McFadyen's office released the report Thursday morning and scheduled a news conference to discuss the findings. 

In an emailed statement released shortly thereafter, Extendicare expressed its condolences to grieving Parkside families.

The company went on to highlight "systemic" health-care issues in Saskatchewan, including the need to replace aging care homes like Parkside and "sufficient funding to meet the international benchmark of four hours of direct care per resident each day."

Patient zero was a worker who declined early testing

The investigation noted some concerns that Extendicare employees had previously flagged to CBC News, including the company's failure to ensure staff were properly separated between positive and negative Parkside residents. 

The ombudsman's office obtained a trove of more than 20,000 emails, contact-tracing summaries and other documents to piece together the most comprehensive account of the outbreak yet.

The first person believed to have COVID-19 symptoms at Parkside leading up to the outbreak was a direct care worker who later told contact tracers they had felt a headache, cough and dizziness on Nov. 11, followed by a loss of taste the next day.

Some time within the next week, "their doctor told them to get tested for COVID-19, but they did not."

The worker was in close contact with residents at Parkside for two shifts before they started showing symptoms on Nov. 9 and Nov. 10, then worked eight more shifts while still symptomatic from Nov. 12 to Nov. 20, the day health officials declared the Parkside outbreak.

"Though they wore a mask when interacting with residents, they reported working up close with residents in their rooms and during their meals when residents were not wearing masks. This direct care worker also reported sitting unmasked within six feet of other Parkside staff who were also not wearing masks during breaks."

The worker was swabbed for COVID-19 on Nov. 20 and began isolating on Nov. 21.

Extendicare has said it is phasing out four-person rooms at its homes across Canada. Pictured: the exterior of Parkside Extendicare in Regina. (Richard Agecoutay/CBC)

The ombudsman's office asked Extendicare for records indicating that the worker's temperature had been taken before they entered the building. Parkside had a dedicated screener checking staff temperatures and ensuring proper documentation was being completed, according to the report. 

"For two weeks, Parkside told us they were looking for [the records], but could not find them. Eventually, Parkside's administrator told us the policy was that they only had to be kept for 30 days, so they had been destroyed."

'I know exactly where I got it: in the staff room'

Over the course of the outbreak, 132 Parkside workers contracted COVID-19, alongside 194 of the nursing home's 198 residents. 

Staff reported wearing masks while dealing with residents, but that practice sometimes ceased once workers entered the break room, according to the report.

A direct care worker who worked shifts after feeling symptomatic and eventually tested positive said there were often more than 10 people in the break room, so it was not possible to maintain social distancing.

"[The worker] told us they sat in the break room while symptomatic and unmasked across a two-foot table from other staff, who were also not wearing masks," according to the report. "The worker told us they also took breaks in the resident's lounge â€" a room near Parkside's front entrance â€" where they and other workers were within two metres of each other without masks on while they ate during their breaks."

Another worker who tested positive said, in hindsight, staff should have been monitoring each other more closely.

"I know exactly where I got it: in the staff room," they said. 

Yet another worker said they had carpooled, worked the same shifts and stayed at the same hotel as a co-worker. They did not wear masks when they carpooled. They both tested positive for COVID-19.

"Some staff reported being harassed if they needed to stay home because they were symptomatic."

1 mask per shift 

Even during the leadup to the Saskatchewan Health Authority taking over operations at Parkside in early December 2020 â€" well into the outbreak â€" Parkside staff were still being given just one mask and a paper bag to store it in per shift, instead of the four masks per person required by the health authority, according to the report. 

Extendicare's local and regional managers resisted following the proper rules "apparently, it seems, for no good reason."

In one Dec. 17 email cited by the ombudsman's office, Extendicare's regional director expressed disappointment with the "new" provision that residents had to be masked outside their rooms. In fact, that rule had been in place provincewide since Nov. 18.

"By the time the regional director sent his email, the authority had taken over Parkside because Extendicare had not been able to effectively respond to the outbreak, almost all of Parkside's residents had contracted COVID-19, and many of them had already died," according to the report.

"In hindsight, then, it seems to us that the additional effort of Extendicare's staff to ensure residents wore masks outside their rooms, and the additional hardship on those residents who could not wear them and had to remain in their rooms, would have been well worth making and dealing with if it meant more lives would have been spared."

'Too late for Parkside'

The report is not without its criticisms of the Ministry of Health or the Saskatchewan Heath Authority, which contracts Extendicare to operate Parkside.

Extendicare lobbied the ministry beginning in June 2020 to bring on-site rapid testing to Parkside and other Saskatchewan homes.

But it was not until after the outbreak started at Parkside that the health authority acknowledged to Extendicare that its screening measures were becoming less effective and said it had started piloting on-site rapid testing in some facilities, including at Extendicare's nursing home in Moose Jaw.

Rapid testing was implemented at Parkside beginning on Dec. 8, around the time the health authority took over operations. 

"By the time the ministry and the authority introduced on-site rapid testing in Saskatchewan, it was, of course, too late for Parkside," according to the report.

The ombudsman's report also details lobbying efforts by Extendicare dating back to 2010 asking the province to replace the aging Parkside facility, which was built in the mid-1960s.

In one of four recommendations to the Saskatchewan Health Authority, the ombudsman's office called on the authority to take greater steps to ensure "all operators it enters into agreements with to provide services are required to comply with care-related policies, standards and practices, including infection prevention and control measures, that are acceptable to the authority."

CBC News has reached out to the ministry and the health authority to see if they will be commenting on Thursday. 

Read the full report below. Don't see it? Click here. 

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