Seven Oaks, where 16 have died in the COVID-19 crisis, had infection control problems flagged by inspector last year

A Scarborough nursing home where at least 16 residents have died from COVID-19 had flaws in its infection control protocols meant to detect and reduce outbreaks, according to an October 2019 inspection report.

The report by the Ministry of Long-Term Care found Seven Oaks nursing home failed to follow regulations requiring the home to analyze and track residents’ symptoms that were recorded during daily shifts.

The inspection reviewed outbreaks at the city-run home on eight separate dates, including a recent illness that affected nine residents.

There was no evidence the sick residents’ symptoms were “analyzed daily to detect the presence of infection or that they were reviewed at least once a month to detect trends to reduce the incidence of infections and outbreaks,” the report said.

In a statement, a city of Toronto spokesperson said Seven Oaks’ “past deficiencies were all addressed prior to the COVID-19 outbreak and were not a factor” in the ongoing infections at the home.

Seven Oaks “completed a comprehensive review” of its operations following the inspection, including “immediate changes in the nursing management team,” the statement said.

“Since October 2019, Seven Oaks has made significant improvement as a result of the management changes and actions taken to address identified deficiencies.”

Among those changes are a new director of nursing and the addition of two new nurse managers, one with extensive infection control experience who has “worked closely with the leaders in the home to ensure all infection, protection and control protocols were implemented,” the statement said.

There have been 16 COVID-related deaths at Seven Oaks, with four other recent deaths in which the cause is still being investigated, Dr. Eileen de Villa, Toronto’s medical officer of health, said Wednesday.

The besieged facility was also one of two Toronto nursing homes where faulty surgical masks were distributed. The city is investigating whether any staff were exposed to the virus because of the faulty protective gear.

There have been 45 confirmed cases and another 56 probable cases at the 249-bed home, located on Neilson Rd. near Ellesmere Rd and Morningside Ave. De Villa said there have been 13 confirmed cases among the home’s staff.

“We are starting to see a positive effect of the stringent outbreak measures that have been put into place throughout the home and the rate of new infections is starting to slow down,” she said. “Unfortunately, we anticipate there may be additional deaths among those residents who have become ill with COVID-19 over the last few weeks.”

The Star reviewed recent inspection reports of more than 50 Ontario nursing homes that, as of early April, had patients suffering from COVID-19 or another outbreak.

The inspection reports reviewed by the Star were from January 2019 to January 2020 and predate COVID-19.

At a small number of those homes, inspectors had found problems with infection prevention and control practises. At one Toronto home, for example, a staff member was seen tending to a sick resident whose room was under “droplet precaution,” then not washing hands before attending to another resident.

Dr. Eileen de Villa, Medical Officer of Health for the City of Toronto, said Wednesday there have been 13 confirmed cases among the nursing home's staff. "We are starting to see a positive effect of the stringent outbreak measures that have been put into place throughout the home and the rate of new infections is starting to slow down," she said.

At Scarborough’s Seven Oaks, the home was aware that its internal analyzing of outbreaks was insufficient, according to the inspection report. The inspector reviewed internal records that showed the “home recognized that the (infection prevention and control) program did not meet all its objectives,” and that Seven Oaks had previously flagged that its “process to collect and analyze consistent data in a timely manner” was an area it sought to improve.

Another recent inspection, from November 2019, found that more than 30 per cent of the home’s staff in 2018 had not completed mandatory training in infection prevention and control.

A Toronto city spokesperson said the “leadership team at Seven Oaks completed hands-on (infection prevention and control) training for 100% of their staff in 2019.”

“We take all inspection findings very seriously and developed a comprehensive action plan to address deficiencies and ensure sustainability,” the spokesperson said in a statement.

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Outbreaks of any kind can have devastating consequences, and with COVID-19, the importance of “tracking of disease and virus through long-term care is evident to everybody,” said Laura Tamblyn Watts, CEO of CanAge, a national seniors’ advocacy organization.

When homes stumble in their requirements to track this data, it’s most often the product of a lack of resources, she said.

“What you see in those incidents reports, in my opinion, is rarely long-term care homes that aren’t trying. What you see is long-term care homes that are chronically understaffed, under-funded, having to make incredibly difficult choices with the few hours of staff that they have,” she said.

Tamblyn Watts said there needs to be more robust support — both in expertise and funding — to help long-term care homes better track and prevent outbreaks.

“We talk about seniors but we don’t fund seniors. Seniors are in our hearts and minds but it doesn’t translate into pocketbook dollars,” she said.

A strong surveillance system is critical in preventing outbreaks and mitigating their damage once they’ve penetrated the walls of a long-term care home, said Dr. David Walker, a professor in the department of emergency medicine at Queen’s University.

“In normal times, the preparation for and the ability to then manage an outbreak in a nursing home is key,” he said. “They’re a highly vulnerable population and they’re in close proximity.”

Walker was one of three authors of an expert panel report into the 2005 Legionnaires outbreak that swept through the same Seven Oaks nursing home, infecting 70 residents, 39 staff and 21 visitors. The disease, a type of pneumonia caused by a bacteria found in water, killed 23 residents.

The expert report concluded that the sick residents received “exemplary care in Seven Oaks,” where “staff responded effectively to the increase in demand for care, even though a number of staff were off sick.”

The report found the home responded “appropriately and quickly” to reduce the spread of Legionnaires within the home.

Walker cautioned against drawing a “straight line” from the inspection findings to the COVID-19 outbreak inside the home, adding that one has to consider how “capricious” and “virulent with frail, old people” the virus has proven to be.

“The nastiness of this coronavirus, I think, would clearly test any organizational preparedness,” he said.

Provincial inspectors visiting Seven Oaks in 2019 flagged other concerns with the home’s infection control. A November report described an inspector watching a nurse drop a pill on the ground, pick it up and administer it to a patient. In a March 2019 report, the inspector found a staff member washing supplies used to treat a resident so they could be re-used the following week, which went against the home’s protocols.

The city said Seven Oaks has addressed the deficiencies flagged by the inspections.

Jesse McLean

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