Shirley Egerdeen had only lived at Forest Heights Long Term Care for two and a half months when she died, with no one at her bedside, sometime in the early morning of April 22.
She had been diagnosed with COVID-19 a couple weeks before.
Her surrogate daughter, Tracy Rowley, received a call at 4:30 a.m. with the news of Egerdeen’s death. She says she was given three hours to arrange for Egerdeen’s body to be moved to a funeral home.
Rowley told HuffPost Canada her first question that morning was, “Was she alone?”
“It’s painful to think that not only did she die alone, you can’t even tell me how long she might have been dying ...”
“The lady said, ‘We went in to check her dressing at four o’clock and she was not breathing.’ Therefore she was alone. How long was she lying there not breathing? I don’t know,” Rowley said.
“It’s painful to think that not only did she die alone, you can’t even tell me how long she might have been dying, like might have been lying there not breathing,” she said through tears.
A total of 45 people have now died as part of a COVID-19 outbreak at Forest Heights, according to numbers published by Revera Inc., the private company that runs the home.
Rowley has other questions for Revera, which runs dozens of long-term care and retirement homes across Canada. Like, how did the deadly novel coronavirus spread from Forest Heights’ second floor, where Rowley says staff told her it first appeared, to Egerdeen’s room on the third? Why did a doctor tell Rowley that Egerdeen would stay in her shared four-person room after she tested positive? And if Revera had isolated residents differently, would the woman she called “Mom” still be alive?
Earlier: Premier Doug Ford says his ‘heart breaks’ for people in long-term care. Story continues after video.
Revera spokesperson Larry Roberts told HuffPost Canada in a statement that the company cannot comment on any of the details about individual residents in this story “out of respect for the residents’ privacy and the privacy laws under which we operate.”
Rowley had known Egerdeen for more than 10 years. The pair developed a close relationship after Egerdeen hired Rowley to clean her apartment in Kitchener, Ont. Their birthdays were three days apart, so the two Libras always celebrated together with Swiss Chalet takeout and “Law and Order” marathons.
“Shirley is a very feisty, independent woman,” Rowley said.
“We grew a bond because she did not have a spouse or any children. So she started calling me her adopted daughter, and she kept saying, ‘I have a daughter and I didn’t have to go through the pain, yay!’”
Rowley is the executor of Egerdeen’s estate and a representative plaintiff in a $50-million class action lawsuit against Revera.
She and family members of other patients, represented by Diamond and Diamond LLP, claim the company was “systemically negligent” in operating its homes and caring for residents, leading to multiple COVID-19-related deaths.
At least 164 people have died after contracting COVID-19 in 12 of Revera’s long-term care and retirement homes, according to updates posted on the company’s website. There have also been outbreaks at dozens of other Revera homes that have not reported any deaths.
Roberts told HuffPost that Revera is reviewing the lawsuit and will respond through the courts.
“However, we will not let it distract us from our singular focus at this time, which is to prevent further illness and loss of life,” he said.
A spokesperson from the Ontario’s Ministry of Long-Term Care told HuffPost that what’s happened at Revera homes and others across the province is “tragic.”
The province has provided $243 million in emergency funding to support long-term care homes with needs like hiring and retaining staff, ministry spokesperson Macey Aramburo said in a statement.
In interviews with HuffPost, staff and relatives of those in Revera facilities said residents who tested positive for COVID-19 or who had contact with suspected cases were not isolated, nor did the company provide staff with personal protective equipment (PPE) until the outbreaks were well underway.
The family members also said Revera has told them very little about the impact of the outbreaks on their loved ones.
“We’re actually getting calls from workers both past and current who are saying, ‘You guys don’t even know the half of it.’”
Diamond and Diamond lawyer Darryl Singer said his office has signed up more than 1,000 plaintiffs — residents of Revera-owned homes or their family members — who have joined the class action since it was announced April 30.
“A lot of what we’re finding is that not just the residents are upset … We’re actually getting calls from workers both past and current who are saying, ‘You guys don’t even know the half of it,’” Singer said.
“My firm has sued Revera in other lawsuits completely unrelated to this and going back a number of years. So this negligence, the lack of preparation, is not surprising.”
Revera is no stranger to lawsuits and accusations of neglect. Last year, there were at least 85 active lawsuits against the company countrywide. Past Diamond and Diamond lawsuits were settled out of court and at least one is still in progress, Singer told HuffPost.
“When we talk about negligent care of the residents, it didn’t start in February, when COVID broke out,” he said.
Employee says homes were not prepared
But when the breakout hit, Revera was not ready, according to one employee.
Management at Revera’s Carlingview Manor Long Term Care in Ottawa, where 38 residents have died, did not have a plan in place to stop the virus from spreading once it was diagnosed in patients and staff, a worker said in an interview. HuffPost is keeping this person’s identity confidential because they’re afraid of losing their job.
“They weren’t prepared at the beginning for something like this,” the source said.
Some Carlingview Manor employees are refusing to report to work because they’re afraid of bringing the highly contagious virus home to their children or elderly parents, the source said.
The first person to go into self-isolation at the Ottawa home was a housekeeper who worked on the seventh floor, according to the employee. His temperature was taken at the end of a shift and it was high. He was asked not to return to work, but the residents on the floor where he worked were allowed to keep moving around the home and go to the dining room, the source said.
After an outbreak was declared April 2 at Stoneridge Manor in Carleton Place, Ont., a senior Revera staffer went there to help out and then returned to work at Carlingview Manor, which had not yet reported a case of COVID-19, the employee said. Six days later, Carlingview Manor was hit with its own outbreak.
The Ontario government later issued an emergency order restricting long-term care home staff to a single workplace.
‘Very aggressive virus’
Revera’s spokesperson said health-care workers were not initially looking out for pre-symptomatic or asymptomatic spread, but it turned out to be a “significant contributor” to the outbreaks at both Carlingview Manor and Forest Heights.
“COVID-19 is a very aggressive virus that spreads quickly. We are learning more and more about it every day,” Roberts told HuffPost in an email.
“In hindsight, Ontario has learned that allowing staff to work at multiple healthcare locations was a contributor to the spread of the disease. This is particularly true of Revera homes, where, since mid-March, we closed all of our residences and long term care homes to all but essential visitors.”
He said limiting staff to one work site was hard to manage because it caused staffing shortages.
“As a result, it was only implemented recently by government directive.”
Roberts also said that the company is grateful for the “heroic” work of its staff. “Our teams have truly exhibited compassion, courage and determination.”
Carlingview Manor staff have more than enough PPE now, the source told HuffPost, but they worked without it in the early days of the outbreak, even after residents had tested positive. And staff still have questions about why some nurses have received N95 masks but PSWs have not.
Managers give “relaxed, nonchalant” answers when pressed about PPE, and employees have found unopened boxes of N95 masks that were never offered to them, the worker said.
Revera’s spokesperson said all of the company’s homes have had access to “sufficient and appropriate” PPE and that it has complied with Ontario government directives about its usage.
A May 3 briefing note from Public Health Ontario states that N95 masks only need to be worn during certain procedures.
“It’s beyond a paycheque right now because, honestly, I don’t think Revera cares much about their employees.”
The employee said they are still going to work out of concern for the patients.
“We’re doing the best we can. We’re there for the residents,” the employee said. “It’s beyond a paycheque right now because, honestly, I don’t think Revera cares much about their employees.”
Kitchener Centre MPP Laura Mae Lindo said staff at Forest Heights, where Egerdeen died, have told her Revera refused to let them wear PPE. She spoke with front-line staff in long-term care homes, including Forest Heights, in late April.
“Front-line workers told us that the extent of the crisis could have been prevented if staff had been allowed to wear the Personal Protective Equipment (PPE) that they had been fitted for at the beginning of the pandemic,” the NDP MPP wrote in a letter to the premier and Health Minister Christine Elliott that was shared with HuffPost.
“Staff have shared that PPE was taken away once it was already on the floor, and that the main reason given was that residents, especially those with dementia, would be scared by the masks,” Lindo wrote.
“PSWs who had tested positive for COVID-19 but were asymptomatic were told that they had to continue showing up for work because staffing shortages plagued the home.”
Forest Heights did ask “a few critical healthcare workers to come in, very early in the emergency outbreak situation, after being asymptomatic for 72 hours following a positive test for COVID-19,” Roberts, the Revera spokesperson, confirmed in his email to HuffPost.
The practice was consistent with an April 15 government directive that said “in exceptional circumstances,” critical workers who test positive but do not have symptoms can work, Roberts said.
“They were not sick at the time ... Furthermore, this was always a very last resort from a staffing perspective,” he said.
“That’s horrendous ... That is just appalling,” said Shepherd, a retired registered nurse.
She said her world “went rock bottom” when she received the call with the diagnosis for her mother, Martha Grace.
The doctor on the phone provided zero information about how Grace would be isolated or cared for now that she had the virus, Shepherd said.
“I asked him on April 22, ‘When will mom be retested?’ And he said to me, ‘We’d have to refer to the public health unit.’ Like, he didn’t even have a plan back [on] April 22.”
Shepherd said she and other residents’ relatives are relying on the news for updates because Revera isn’t sending them any information.
Revera’s spokesperson did not address HuffPost’s questions about the company’s communication with families.
The ministry of long-term care spokesperson said every licensed long-term care home has been assigned a ministry-support person, and added that provincial inspectors “have been in regular contact with Revera homes to ensure they are getting the support they need related to staff capacity, outbreak status, personal protective equipment supply and other critical needs.”
Bodies moved within three hours
Relatives of Carlingview Manor residents also say the lack of communication has been agonizing.
Debbie Clarke’s brother Bill has been a resident at Carlingview for about 10 years. He tested positive for COVID-19 in late April.
After phoning for more information about her brother when he tested positive, Clarke received a call back from a nurse who instead asked about Bill’s funeral arrangements. She was told his body would be removed from the home within three hours of his death, and she might not be notified until after his body was moved.
When Clarke couldn’t get through to anyone at the home in the days following that call, she worried her brother had died and no one told her. Four days later, someone at the home picked up her call and she learned that Bill was still alive.
“For those four days that I couldn’t get anybody, I said, ‘What? I’m waiting for the funeral home to call me?’”
“It is a directive we do not enjoy following and that is particularly difficult for our staff.”
The three-hour policy is not Revera’s, the company’s spokesperson said, but rather a direction from the chief coroner’s office.
“It is a directive we do not enjoy following and that is particularly difficult for our staff,” Revera’s spokesperson said.
Ontario’s chief coroner, Dr. Dirk Huyer, told HuffPost that families need to choose a funeral home within three hours but have more time to make the rest of the arrangements.
“It’s not a hard rule … it’s a goal to achieve,” he said by phone Monday.
Funeral home staff are available at all hours to pick up the deceased from hospitals and long-term care homes so there isn’t a backlog in the morning, he said. These policies are “horrible” but necessary during the pandemic to avoid overwhelming funeral homes, he said.
Although she occasionally gets to talk to her brother, Clarke said she continues to have trouble getting through on the phone to be connected to the sixth floor, where he lives.
Clarke said she had been told by a nurse that her brother’s roommate was showing COVID-19 symptoms. When she asked how his self-isolation would work, she said she was told they would still share the bathroom, but there was a curtain separating their spaces.
Her brother’s girlfriend Jennifer, who also lives at the home, had been her lifeline, texting and calling with information that Clarke couldn’t get from the nurses, or from her brother, who continually lost the cellphones she has given him.
But Jennifer recently stopped responding to messages, and a text sent from her phone revealed she is now in the intensive care unit. Clarke doesn’t know whether or not she’s alive, and because she’s not family, she can’t get any information.
Still, she said she is grateful for the work the staff are doing. She prays for the nurses and their families. But she’s also worried the home could see a situation like the one in Dorval, Que., where long-term care home staff walked out and 31 residents died. (That home is not owned by Revera.)
“I’d be scared s**tless if I was them, going into a home that’s so bad,” Clarke said through tears. “What’s stopping them from saying, ‘I’m not going into work today?’”
‘Worst nightmare come true’
Christine Collins found out that her brother Peter tested positive for COVID-19 in late April. Peter, who has dementia, has been complaining of a migraine and shortness of breath, but he doesn’t seem to know his test result: either he wasn’t told by staff, or he has forgotten it, Collins said.
She doesn’t want to tell him, to try to keep him in a happy mood.
Peter, 68, is on a secure floor for residents with dementia. He was in self-isolation for 14 days after being transferred from the Ottawa Civic Hospital, where he was treated for non-COVID-19 health issues. When his isolation period ended, Peter was allowed to leave his room and go to communal areas — even though an outbreak had been declared at the home six days earlier.
Peter likely contracted COVID-19 during that time, Collins said.
Even when he was in isolation, other residents wandered in and out of his room. Collins said a nurse told her it was Peter’s responsibility to make sure other residents didn’t come in.
“No one is in isolation on that floor,” Collins said.
The day her brother tested positive, Collins said she phoned the nursing station multiple times before a resident answered and cracked a joke about expecting a call from a famous singer about their wedding.
“And so I asked her, ‘Is there somebody there besides you that I can talk to?’”
The resident told her there wasn’t.
Collins calls the situation her “worst nightmare come true.” She keeps detailed notes of her calls to Carlingview. “I’m writing notes all the time, because at the end of the day, something has to happen.”
Neither Collins nor Clarke is currently part of Diamond and Diamond’s lawsuit against Revera, though Collins said she is considering joining it.
Rowley shares their concerns about how residents with COVID-19 were isolated at Forest Heights, the Kitchener home where Egerdeen died.
Patients isolated with curtains
Egerdeen, who shared a ward room with three other residents because that was what she could afford, was diagnosed with COVID-19 in early April.
Rowley recalls her conversation with the doctor that day: “I asked, ’OK, going forward, what are we doing to make sure we isolate her because, remember, she’s in a ward. He said, ‘We put the curtain around her.’
“A lot of concerns of mine came up at that point.”
“... they did nothing to prevent this.”
Within a week, Rowley said, two other residents in Egerdeen’s room had confirmed cases of COVID-19.
“Same thing happened. Their curtains were closed. That was it,” she said. “So they did nothing to prevent this.”
The statement from Revera’s spokesperson did not address questions about how residents were isolated once they tested positive for COVID-19.
Both Rowley and Shepherd said they had no problems with Revera before the outbreak and described the staff at Forest Heights as upbeat, passionate and caring.
Revera was warned by inspectors
Inspection reports from the Ontario Ministry of Long-Term Care, however, show that Revera was warned in the months leading up to the pandemic that it was not following ministry requirements to protect residents from abuse and neglect.
In May 2019, a provincial inspection found that Forest Heights had failed to protect residents from physical and sexual abuse.
That fall, Revera was warned about failures to protect residents at Forest Heights from staff neglect. The ministry inspector noted:
- Residents with wet beds,
- Staff sometimes forgot to brush residents’ teeth and change their diapers,
- Protocol had not been followed after a resident fell and hit their head.
Carlingview Manor, where Clarke and Collins’ brothers both live, was warned in February that resident’s rooms were not being cleaned properly. An inspector found dead cockroaches, cockroach feces, and furniture so “degraded” it was impossible to keep clean in rooms at the Ottawa home.
Ontario’s government has said it knows the long-term care sector needs an overhaul.
“Our main focus is to make sure it’s all hands on deck at long-term care,” Ford told reporters last Thursday. “We know the system’s broken.”
Minister of Long-Term Care Merrilee Fullerton has promised to review the system after the pandemic passes.
“Long-term care has endured years of neglect. Once we emerge from this pandemic, we will get to the bottom of this,” she said on Twitter last week.
Aramburo, the ministry spokesperson, said “all forms of review” are on the table.
“There will come a time to discuss the scale, scope, and terms of a review, but our priority now must be to protect people’s lives and continue to bend the curve,” her statement said.
“... this year, I’m going to have to put flowers on her grave.”
As for Rowley, she spent a difficult weekend without Egerdeen.
“This Mother’s Day will be very hard, because I would buy her cards, I would call her,” she said last week. “But this year, I’m going to have to put flowers on her grave.”
No service or graveside visit will make up for not being there the morning her mom died, Rowley said.
“I didn’t get to hold her hand. I didn’t get to stroke her hair. I didn’t get to tell her ... ‘I’m here. Don’t worry.’”
Are you an employee or relative of a resident at a long-term care home where there’s an outbreak of COVID-19? Tell us your story. Contact reporters Emma Paling and Sherina Harris at firstname.lastname@example.org and email@example.com.
CORRECTION: A previous version of this article incorrectly said a nurse answered a phone and made a joke. It has been updated to say it was a resident who answered the phone.
CORRECTION: A previous version of this article misspelled Shirley Egerdeen’s name.