How the Maples outbreak became Manitoba's deadliest — and what experts say needs to change

Staff scrambling to separate residents. Halls crowded with untrained workers. Outside help unable to determine who's calling the shots.

Those are some of the details published in an external review into the deadly COVID-19 outbreak at Winnipeg's Maples Long Term Care Home, which experts say highlights issues within senior care — and presents an opportunity to fix them.

The report by Dr. Lynn Stevenson, a former associate deputy minister of British Columbia Health, followed a critical situation at the care home in early November, when eight people died within 48 hours.

While staffing levels had been critical for days, leaders with the Winnipeg Regional Health Authority later told Stevenson they didn't know the "magnitude of the situation" until Nov. 6, the day paramedics were called to the facility to care for a dozen rapidly deteriorating residents. Two residents receiving end-of-life care had already died by the time ambulances arrived.

The deadliest outbreak at a Manitoba care home to date started one Sunday a few weeks earlier, when a resident on the building's second floor started showing symptoms of the illness caused by the novel coronavirus, Stevenson's report says.

An outbreak was declared at the 200-bed facility, owned by the for-profit company Revera, on Oct. 20. By the time it was over nearly three months later, 157 residents had been infected, including 56 who died, Health Minister Heather Stefanson said on Thursday. Seventy-four workers were also infected.

'Chaotic workplace'

As more workers self-isolated, staffing shortages became critical. Ten days into the outbreak, that was affecting the home's ability to care for its residents, the report says — but pandemic plans didn't direct the care home to proactively ramp up staffing or detail what to do when it started losing workers.

"It seemed like [the province] somehow thought we weren't going to have large outbreaks," Michelle Porter, director of the Centre on Aging at the University of Manitoba, said in an interview with CBC.

"We focused most of our planning around personal care homes on keeping the virus out," she said, and when large outbreaks hit, "the system wasn't able to handle them."

Leaders from Manitoba's health incident command structure said they weren't initially told about the worker shortages. Staffing situations like the Maples saw are supposed to trigger a "system-wide response" under provincial policy, the report says.

That didn't happen, and it's not clear why.

Outside clinical staff said when they arrived, they couldn't tell who was in charge of the site's pandemic response. 

Halls were crowded with extra untrained workers brought in to address shortages — though their roles were unclear and they weren't trained to care for residents, which created more work for existing staff.

Meanwhile, personal protective equipment breaches and overflowing garbage bins created a "chaotic workplace," the report says. 

"What this report laid bare is that [even] a home which did fairly well pre-pandemic is held together, in many cases, by string," said Laura Tamblyn Watts, CEO of CanAge, a national seniors' advocacy group.

"If external pressures like infection come to play, then that string can get pulled and snapped."

Confusing documents, cohorting distress

When staff shortages became "critical" at the end of October, Revera contacted 36 staffing agencies, offered paid practicums to students, and submitted requests to the provincial recruitment and redeployment team, as well as the Winnipeg Regional Health Authority, the report says.

The situation was exacerbated by provincial long-term care guidelines that buried the care home in "confusing, unwieldy" planning documents, the review says, many of which were longer than 10 pages or had several versions.

It's not about rearranging the deck chairs on the Titanic. Fundamentally, it's making sure that you have a ship which floats.- Laura Tamblyn Watts, CanAge

At the same time, added protocols burdened already taxed workers, like the requirement to cohort residents based on their COVID-19 test results.

That involved staff moving each resident, their bed and their personal belongings — sometimes several times — then thoroughly cleaning their room, the review says.

"This was very time consuming for staff during a period of critical staff shortages and may not have been necessary for a facility where residents already had individual (not shared) rooms," the review says.

But both Tamblyn Watts and Porter said the question isn't why workers had to keep cohorting people — it's why Maples staff didn't have the help they needed in the first place.

"It's not about rearranging the deck chairs on the Titanic. Fundamentally, it's making sure that you have a ship which floats," Tamblyn Watts said.

"The real answer at play is more staff with better supports in place and less worrying about how to make do with what we know already isn't enough."

Understaffed, overworked

The "overwhelming" staff shortages the Maples saw during its outbreak made some workers, who knew it would be hard to replace them, feel guilty when self-isolating, the report says.

Some ended up working as many as 12 weeks without a day off, or sleeping at the care home so they were available to work and wouldn't risk exposing their families to COVID-19, it says.

Those shortages, which often saw staffing below 70 per cent of normal levels, were compounded by the gap left by families who were no longer allowed to visit, and so couldn't help with resident care.

At the same time, some key positions at the care home went unstaffed after COVID-19 testing sent people home to self-isolate, the report says.

That included the facility's scheduling clerk — a "highly problematic" job to fill — and several workers trained to screen people at entrances, who the facility "did not have a backup plan" to replace.

"There are barely enough staff to keep the homes running at the best of times, and this report made clear how thin the bench strength really is," Tamblyn Watts said.

The review makes 17 recommendations, including several linked to funding and planning in care homes, which Manitoba's health minister has committed to implement.

A plan detailing how that will happen will be made public within 30 days, Stefanson said.