Nurses recall scenes of neglect disorder and horror at inquiry into Quebec long-term care home

One nursing home resident was in his bed, hooked up to an oxygen tank that no longer had any oxygen. He had bandages so old they had turned yellow, his skin beginning to grow over them. Another resident had become so dehydrated their blood had become thick, and was difficult to draw for testing.

"When we gave them water, they would take the glass of water like they had just come out of the desert. They wanted more and more and more," said Stéphanie Larose, a nurse called upon to provide relief at the Herron nursing home in Montreal's West Island in early April 2020.

At times in tears, Larose described appalling conditions Thursday at the coroner's inquest into the privately run nursing home in Dorval, Que., where 47 people died during the pandemic's first wave. The inquest is part of a larger examination of the problems in the province's long-term care homes.

Larose said Herron was lacking basic medical equipment to take oxygen levels when she first began relief shifts at the care home on April 3, and it quickly became clear that basic needs were not being met.

"If you do nothing else, give them water," she recalled telling staff. "If you don't have time to change their beds, at least give them water."

Hot and cold zones to separate those who were infected with COVID-19 were not established until April 13, she said.

Bureaucratic confusion

For a third day at the inquest in Longueuil, Que., coroner Géhane Kamel tried to shed light on the crisis at Herron.

But precisely what led to the confusion around who was in charge â€" and the lack of co-operation between Herron and the West Island health authority that oversees it â€" remained unclear during Thursday's questioning.

Staff from CIUSSS de l'Ouest de l'île de Montréal, the health authority that oversaw Herron, were on site beginning March 29, even though the first signs of trouble came two days earlier. And the health authority only formally took control of the facility on April 9. 

The Herron owner, meanwhile, sent a letter to the provincial government that same day, saying the local health authority was not equipped to deal with the situation.

By April 10, 31 people had died at Herron, and the CEO of the health authority phoned the police for assistance.

Owner seemed 'overwhelmed'

Brigitte Auger, an official with the health authority who acted as an intermediary between the authority and the home during the crisis, offered insight into the lack of communication and preparation in her own testimony earlier Thursday.

Auger said Herron's owner, Samantha Chowieri, appeared "completely overwhelmed" when she got to the facility on the evening of March 29. The hallways were quiet and dark, and residents had not been fed supper, Auger said.

Chowieri was in an office with an employee, trying to contact staff. Auger said Chowieri appeared to "not have that much experience" in dealing with the management of the facility.

Coroner Géhane Kamel, right, is assisted by Dr. Jacques Ramsay, a coroner with medical training, in presiding over the inquiry, which is taking place in Longueuil, Que. (Charles Contant/CBC)

Auger said only two orderlies, along with one of her own colleagues, were in the building that evening to help care for 131 residents.

Many staff had already contracted COVID-19 and were quarantining at home, the inquest heard earlier. Auger, who was not a trained nurse, said she walked from room to room, checking on residents. 

"I got into help mode," Auger said. "I am not a practising Christian, but I did the cross in my head, and I wanted to find, in each room, a living person."

Lack of urgency troubling, lawyer says

Fateh Belarbi, a nurse who was called to assist as the night co-ordinator on March 29, said Chowieri was helpful as he tried to address the problems at the site.

But he said there was a clear lack of gloves, masks, visors and gowns when he arrived, and some prescription medication hadn't been filled.

Belarbi said he exchanged texts with Chowieri in the coming days but that communication with her stopped suddenly on April 7.

Chowieri is set to testify at the end of the inquest.

In an interview during a break in the inquiry, Patrick Ménard, a lawyer representing some families of Herron residents, said the lack of urgency in the days after March 29 is troubling.

"It seemed that no one had the reflex to say, 'Look, we have patients here who are dehydrated. We have patients here who require oxygen and we don't have enough oxygen on the side,' " he said.

"It seems that no one really had this thought, and that is a problem."

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