Rosslyn lacked 'true understanding' of importance of infection control, says official

The director of Hamilton's emergency operation centre says the Rosslyn Retirement Residence lacked a "true understanding" of the importance of infection control and provided officials with "conflicting information" about protective equipment at the home.

Paul Johnson described a "chaotic scene" on May 15 when dozens of residents were evacuated from the home amid a COVID-19 outbreak that's infected 64 residents and 20 staff members. Four people who lived there have died.

A debrief following that night exposed breakdowns at the home in many of the most basic and critical steps needed to protect staff and residents, more than two months into the pandemic.

The crisis there has prompted officials to increasing inspections at other homes owned by the same group, and to embark on mass-testing of staff and residents at some of those homes. Officials have also developed a set of recommendations on outbreak management in such settings based on what happened and shared them with the province.

Screening "not happening"

Johnson highlighted several factors that led to the dire situation at the Rosslyn during a media update Friday.

"There did seem to be a lack of true understanding in the training and the knowledge around how important infection prevention and control is," he explained.

Screening of people coming in and out of the building was "simply not happening," Johnson added, noting "that encourages spread within a home."

"At times conflicting information was provided. At one stage it was enough PPE was there and then of course we found there wasn't," he said. "Quickly we were able to find PPE, but also appeared PPE was not always being used in the most appropriate way within the home."

The Rosslyn has not responded to repeated phone calls and emails requesting comment on the situation at the home.

On Friday officials declined to say what explanation the home's owners have provided them for how the virus was able to spread so rapidly.

Johnson pointed to "breakdowns," including an incomplete picture of who was still in the home, who had already been transferred made the transfer difficult.

In the end, one resident was left behind after the home was emptied. His absence wasn't discovered until nearly a day later after family members insisted he was not in hospital.

Winnie Doyle, executive vice-president of clinical operations at St. Joseph's Healthcare Hamilton, previously told CBC there were no regular employees from the Rosslyn working by the time the transfers began and the hospital and LHIN staff called were not provided with an up-to-date master list of residents.

She cited another problem too.

"We had been told by the home that the individual had been transferred to the hospital earlier in the week."

Following the mass-transfer and forgotten patient, hospital staff reviewed what had happened, along with public health and the LHIN and created a series of recommendations, said Rob MacIsaac, CEO of Hamilton Health Sciences. 

Clearer roles and accountability

"The severity of the situation at the Rosslyn Retirement Residence cannot be understated," stated MacIsaac.

The list includes testing for both residents and health-care workers on retirement homes, starting with sites considered high-risk as well as determining clearer accountability roles and and responsibilities for people who work in congregate settings. 

It also calls for a stronger regulatory regime for retirement homes and working out a formal command structure at the municipal level for any future evacuations of homes.

Emptying the home was "critical for the well-being of the residents who were living there and immediate action had to be taken," he added.

On Friday Johnson said while the transfer operation was a "collective effort" and officials are looking for a way to "tighten up" the process, the decision to completely clear the home was ultimately up to the Rosslyn's operators.

"That facility was always the Rosslyn's to own and operate and manage," he said, adding that when staff left following a final sweep of the building it was up to the owners to secure it.

Mayor wants 'more teeth' for regulator

Following the outbreak public health began urgently inspecting seven other homes associated with the owners of the Rosslyn.

Dr. Elizabeth Richardson, the city's medical officer of health, said Friday they will be ordering four of those facilities to improve infection controls based on concerns around infection control and screening.

"We're also going to extend mass-testing to take place at four of the homes, Montgomery Lodge, Northview Seniors Residence, Dundas Retirement [Place] and Cathmar Manor," she added.

Richardson said those facilities are considered "highest-risk" in Hamilton and results of that testing is expected Friday evening or over the weekend.

Mayor Fred Eisenberger said the situation at the Rosslyn highlights the lack of "fundamental responsibility" when it comes to retirement homes, leaving residents vulnerable.

"[I] certainly call on the province to put more teeth into the regulatory regime so that these things can be prevented well in advance of them getting to this point."