REPORT: COVID-19 Second Wave Survey of Staff in Long-Term Care Homes with Large Outbreaks

Posted: December 18, 2020

(December 18, 2020)

The Ontario Health Coalition had been conducting surveys of front-line staff in homes with large outbreaks (more than 10 staff and/or residents infected) across Ontario from mid-November to December of 2020. We have collected 88 surveys filled in by long-term care staff who work in dozens of different long-term care homes that have been in large outbreak at the time that the survey was conducted. In our definition of “large outbreaks” we included homes with more than 10 residents or staff infected with COVID-19 and the range included homes with outbreaks with more than 150 staff and residents infected. Homes ranged in size from 55 beds to more than 540 beds. We received surveys from all regions of Ontario. 75% of the surveys were from staff working in for-profit homes, 10.4% were from staff in non-profit homes, and 14.6% were from staff in public (municipal) homes. The surveys were distributed by unions who represent workers and health professionals in the homes affected. We limited the results to no more than three staff from any one home.

 

RESPONSES TO SURVEY QUESTIONS

Do you have enough staffing to provide daily hands-on care to residents during the current outbreak in your home?

Yes- 29.2%

* Note: Some said they have enough staffing with agency staff- 4.2%

Sometimes-4.2%

No – 64.6%

Did not answer- 2.1%

 

If you do not have enough staff, can you describe how short-staffed you are? What types of work cannot be done?

Most staff report inadequate staffing to provide daily hands-on care to residents, and the accounts of what care cannot be done are disquieting. In describing how short-staffed they are, many staff report extraordinary workloads, many report working frequent double shifts, significant over-time requirements, staff unable to take their days off sometimes for weeks at a time, staff unable to take breaks. This issue is vital as care and infection control cannot be done without enough staff to provide them. The surveys provide irrefutable evidence of the devastation caused by provincial government’s failure to address the critical staffing shortages and working conditions in long-term care. While, in April, the provincial government required long-term care staff who have multiple part-time jobs to choose one home in which to work, they expressly exempted agency staff who are allowed to continue to work in multiple homes. At the same time, the provincial government has failed to undertake a coordinated major recruitment drive, has not required homes to provide full-time work to existing staff, has actually deregulated staff training requirements thereby undermining PSWs, and has done nothing substantive to improve staffing levels in the homes. Alarmingly, in the surveys, staff describe homes that are more reliant on agency staff than ever — including a full range of temps from PSWs to RNs — and some describe conditions in which agency staff are deployed to units with no training and no orientation. Others describe dangerously inadequate training. At the same time, multiple staff report that for residents who had extra hired-in support prior to outbreak, those care workers are no longer being allowed into the COVID-19 positive wards, and the PSWs have to add their tasks onto their already overburdened workload. (Note: long-term care homes are supposed to provide adequate safe care without families needing to hire in extra caregivers. The unacceptable reliance on extra caregivers is highlighted by the surveys.)

Staff report that they are short PSWs, RPNs and RNs, housekeeping, laundry, dietary, recreation, rehab and others. The most common element of care that cannot be done is hygiene. Staff report that bathing and grooming cannot be completed at all in some homes, and in others, if completed, are not up to the standards they expect. The other common response is that staff struggle to feed and hydrate all of the residents. Residents are not being fed the entire meal, and if residents had difficulty being fed at meal times, there is not enough time for them to be given food later. Commonly, staff report that meals are delayed. One person said residents are being served sandwiches the majority of the time to make it easier for the home. Several staff report that medications cannot be done or are late. Other types of work that cannot be done are emotional support for residents, talking with residents, cleaning of rooms, social work, and appropriate supervision of PSWs. Tasks that normally require two or more people to perform safely, such as lifts, are being done with only one worker available. This increases the risk of injury to both the resident and the staff member. One staff person reported that they could not cohort residents because of inadequate staffing to do lifts. Staff report that they do not have time to talk with the families of residents. Other work not being done include charting and documentation, including entries to the Ministry of Health website.

Staff also report that housekeeping and laundry departments are often short staffed which directly impacts resident care. They explain that when there are not enough staff to do laundry, for example, it takes even longer to complete their work because they have to take the time to go searching for clean towels or gowns. Inadequate housekeeping has a direct impact on infection control and inadequate laundry staff means that linens cannot be changed as required.

 

Are all staff who are in contact with or exposed to COVID-19 provided with N95 masks and full PPE? Do they have time to change PPE between residents? If not, can you describe how your access to PPE is inadequate?

Yes- 75.0%

No- 25.0%

*Note: Some said they had everything except N95 masks (counted as No)- 2.1%

More than a third of the staff surveyed said they do not have access to appropriate PPE including N95 masks, even now, nine months into the pandemic. This is alarming and unacceptable. In some homes, staff are still reporting being discouraged from using N95 masks. Some who are provided N95 masks, report that it is conditional- they are told N95 masks are only needed if they are with COVID-19 positive residents while aerosol generating procedures are being done, if the resident is on high flow oxygen or nebulizer treatments. Some staff reported that they were not provided appropriate PPE at first during the outbreak, but the home eventually started offering it. .Although some staff were told they would get N95 masks if they asked for them, many described processes that discourage staff from asking, including masks are locked up and require sign out, staff have to find someone to unlock them, staff are encouraged to ration them, staff fear being labelled as a “troublemaker” if they ask for too many. Several staff reported that coworkers did not have N95 masks that are fit-tested. One staff reported that the provision of N95 masks was inconsistent as the home started to run out. One staff reported being required to reuse N95 masks. One staff reported that the management has told them to limit use to one N95 per shift.

Regarding other PPE and supplies, some staff report being provided only one mask per day and are asked to reuse PPE including face shields and masks. Staff report that the PPE is locked up and a number of staff report shortages of needed supplies. Some staff say that they are not provided medical gowns, only industrial ones. Other staff report shortages of gowns, gloves and disinfectant wipes. Staff told us that they struggled to find time to change their PPE between residents, and two workers in different homes reported that they had no time to change PPE.

 

Are all COVID-19 positive residents separated from those who are not infected?

Yes- 79.2%

*Note: Some said yes, but only recently (counted as Yes)- 6.3%

No- 14.6%

*Note: Some said COVID-19 positive residents were separated at first, but now there are too many infected residents (counted as No)- 6.3%

Did not answer or did not know- 6.3%

 

Are there enough staff to stop residents from wandering from COVID safe areas to COVID hot areas?

No- 37.5%

Yes- 25.0%

Did not answer or did not know- 37.5%

 

Are residents locked in their rooms or kept in or out by physical barriers rather than by adequate staffing? Any description you can provide of the state of cohorting COVID-positive and COVID-negative residents would be helpful.

Most staff describe cohorting as being practiced, but there are significant gaps. Some homes took a considerable time during the outbreak before cohorting was done. In other homes, cohorting was done at first, but when staffing became perilously low and with high numbers of infected residents and staff, cohorting was no longer possible. In a significant number of homes where residents are ostensibly cohorted, staff describe residents wandering without enough staff to protect them from wandering into and out of COVID hot zones.

There were disturbing accounts of how homes are dealing with cohorting and critical staffing shortages. Staff report that some residents are being locked in their rooms or are locked within the COVID-19 positive areas. Most staff report that their long-term care homes have resorted to various physical barriers, such as partition-like barriers. Some staff reported the removal of wheelchairs and mobility aids so that residents cannot get up. Power chairs/wheelchairs are taken away to restrict residents’ movement, and sometimes are positioned to block the doorways. We note that there is a serious human rights issue. These methods are reportedly not successful in preventing wandering in a number of homes.

 

Are staff who are COVID-positive but asymptomatic being required to work?

Yes- 14.7%

No- 70.8%

*Note: Some said that they were but only after quarantining (counted as No) – 6.7%

Did not answer or did not know- 14.6%

In approximately 1/5 of the surveys staff reported that COVID-positive asymptomatic staff are being required to work. There are concerns and confusion reported by staff. Under the requirements set out by the provincial government, staff are not required to test clear prior to return to work. However, they are, except in exceptional rare circumstances not supposed to be working if they are COVID-positive and asymptomatic, but there is a loophole in the provincial requirements. Additionally, those staff who are COVID-positive and required to work are supposed to be on work isolation. This does not appear to be happening. In addition to staff being required to work, a number of staff report that workers who have been off quarantining have been required to return to work prior to the end of a 14-day quarantine. Some report that they are required to return after 10-days, one earlier than that. Many appeared to be concerned that staff were not required to test clear prior to returning to work. (This is in accordance with provincial policies.)

 

Are there any other key issues that you believe are contributing to the spread of COVID-19 in your long-term care home that you can describe?

These are staff responses, in brief:

• Had to fight for additional testing- did not test unless there were symptoms.
• Staff who had been infected before were not being tested with the rest of the staff every two weeks.
• Allowing all different type of service in the building: Rogers Cable, maintenance, hair dressing services.
• Things take longer- delivering food trays, collecting dishes, putting on and taking off PPE, paperwork.
• Staff bring it from community.
• Short of qualified staff. Sometimes they sent helpers to help. Helpers are not PSW. They are mostly doing the feeding and some of them can push wheelchairs. This situation made all the regular staff easily burn out or get injured.
• Agency staff are being called in work with little to no experience regarding vital infection control protocols and facility protocols.
• Discouraged from sending residents to the hospital.
• Not enough disinfection.
• Public Health continued allowed these family members entering and staying with residents whether they have COVID or not.
• No negative pressure single room.
• Equipment being shared among rooms (not enough for one in each room).
• Only staff that hasn’t been COVID-positive before are being tested every two weeks, not the staff that have been infected before.
• Bad ventilation.
• Agency staff coming from cities with hotspots.
• Poor management.
• Improper hand/mask hygiene.
• Over-working leads to weakened immune system.
• Residents using shared spaces.
• Lack of a real plan and proper leadership by the management and operator of the long-term care home.
• Staff end up having to work in both the COVID-positive and the COVID-negative parts of the home.
• People are asymptomatic and therefore would not know that they are spreading a virus until the test results have come in.
• Staff who were exposed to COVID-19 positive residents were never told to self-isolate.
• Staff feel that management are not being truthful and communicating with staff regarding what is taking place inside the facility. Management do not come across as supportive and caring during such a stressful time therefore staff are feeling unsafe and unsure of management decisions.
• Non-cohorting of staff between COVID-positive and COVID-negative units.

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SAMPLE OF RESPONSES

Do you have enough staffing to provide daily hands-on care to residents during the current outbreak in your home? If you do not have enough staff, can you describe how short-staffed you are? What types of work cannot be done?

• We work 14 days in a row , missing shower, the food is mostly sandwiches. Agencies staff but not train.
• Most of the time, the staff is short, and residents don’t feed well, morning is okay , activity staff helping for feeding but in the evening is the problem because we don’t enough staff to help for feeding.
• No charge nurse.
• For the PSW staffing, I believe that there are enough staff, but sometimes, it can be a bit short. During times like that, showers may not be given and enough time may not be spent feeding residents.
• We are working on our days off and some are doing 12 and 16 hours shifts also not having time to take our breaks we can’t spend enough time to feed and give good care we are always rushing to go to the next person.
• We recently have become infected with COVID on the wandering floors. We are working 1 registered with 2 or 3 PSWs for 32 residents with more than 50% with positive COVID results. I’m unable to proper assess these residents, due most treatment. I’m not able to get my breaks to rest. We are all so worn out.
• On my night shift under a COVID outbreak we should have 2 PSWs on shift. And there’s only one, me! Out of 16 residents one has passed away, four are confirmed COVID-positive and 10 are symptomatic as you can see its overwhelming work for only one PSW to manage. I cannot give efficient service to 3 or 4 residents who need immediate attention.
• Nursing staff was okay but they were short staffed in housekeeping with only someone available to disinfect high touch areas and dispose of trash.
• The 32 beds unit we should have one RN and 4 PSW plus one PSW for one on one monitor responsive behaviour resident. We only have1 nurse+ 3 PSWs plus one modify PSW who can only do the feeding. Residents got up late and some missed breakfast. When feeding residents it was in a rush and couldn’t finish either food or fluids. Most residents got 1 glass drink which should be 2 drinks minimum according to ministry standard.
• In order to complete our minimum tasks we must for go our breaks, and it is impossible to complete our charting.
• They have one more PSW than before, but due to isolation there is additional work which is making them short staffed. Support workers are no longer entering the COVID+ ward and PSWs are having to do work that support staff would normally do, for example putting away laundry.  Feeding in isolation takes longer and is rushed which cuts into snacks and other services like bathing and grooming which is not being done to the same standard as before the outbreak.
• There have been reduce staff on unit that do not have COVID from PSW to nurses, staff at time is ask to do double shift or come in on days off specially for night shifts, staff sometimes go on long stretch of work days without a day off
• Registered nurses and PSW/HCAs are working double shifts back to back. We are resorting to agency workers who are unfamiliar with the facility and are being put on the unit with no orientation or training and that includes registered nurses who are expected to administer medication. Remaining staff are unable to get time off to rest. Some units have been left without a registered nurse.
• Staffing issues for years. In current outbreak, redeployed staff and agency have been put into place after the initial severity of the first occurrence of outbreak. I am humble to have help, however agency workers were not COVID tested prior, agency workers were finally tested, with positive results. As well as a cleaning company. PPE was not in order upon onset of outbreak. 90-day management taken over.
• Every resident had to be at least supervised while eating in each of their room. Most of them who have COVID deteriorated quite fast – condition changed quickly. Most of them are dehydrated.
• The home started using an agency to fill the gap. But sometimes the agency staff do not show up. They are required to do the online education (Surge) that we the regular staff do throughout the year. If they do not do the online courses they are told not to come back to the home, which then results in our being short-staffed.
• We are extremely understaffed and it takes away from residential care. We need at least 1 staff to 5 residents in order to give the appropriate care and then some.
• They are short staffed in every department. PSW, RPN, RN, dietary, housekeeping, there isn’t enough staff in any of these on any shift
• We need more staff. I worked overtime with only myself and an agency PSW for night shift on a covid unit consisting of 38 civic positive residents. Staff are always working overtime hospital staff that are helping out are not allowed to be working our covid units.

 

Are all staff who are in contact with or exposed to COVID-19 provided with N95 masks and full PPE? Do they have time to change PPE between residents? If not, can you describe how your access to PPE is inadequate?

• In regards to N95 masks and full PPE they are discouraging us from using them. We are being told to use the normal masks and the gowns that we are using are industrial gowns not medical gowns. We don’t have personal access to the masks and the masks are locked in the managers room and they are only given on request. And they are telling us to use the and reuse the masks. We are told to use the N95 mask and take then home at the end of our shift. I was told to bring a container for my mask I brought a tupperware container to reuse the mask for the following day to use for as long as possible.
• In the training video it says that COVID-19 is contact droplet so they don’t need N95 masks. I don’t have access to an N95 so I have to get them to find one for me. The other night they couldn’t find one for me so I had to go out to my car and find one from the day before to use. Other staff are not using N95 masks even in contact with.
• No N95 masks – not recommended by management. Other PPE is being provided. Being asked to reuse face shields. One mask is provided, and I will have to travel to the first-floor screening area to obtain a second clean mask.
• We had COVID outbreak. We don’t have N95. The managers just said even doctors and nursing practitioners did not wear N95 so we don’t need it. I was doing assessment and care to positive residents with simple medical mask and facial shield.
• Originally they were told they could not have any N95 masks unless they were suctioning a patient. When the union spoke to management, management denied that that had been their directions to the RPNs.  They have told them now that they will have access if they ask for them but many do not know when they should ask or do not ask, even though they have told their union they want them.  PPE is fit tested and they have time in between residents to change PPE.
• At the beginning we had PPE except for masks. We now have masks and adequate PPE. However working short we do not have time to change our PPE between residents. I make a point of changing my PPE when I am working with a known COVID or symptomatic resident.
• No at first we had to refuse to work before we get it.
• When it started no N95 but when it spread like a fire then they provided the N95 / complete PPE
• N95 no, full PPE yes staff have time to change PPE yes, the staff has access to PPE.
• From the other units I have heard that since RVH has come to the home, there has been adequate PPE. Prior to RVH I did personally work with someone who waited 6 hours for gloves. We also were required to reuse our same face shields every day from April until the exact day RVH came to the home. I have had to use a hospital gown as a gown because there was no PPE. We also did not have soap for residents for weeks. We had to split soap bottles between residents.
• N95 are only used with Covid positive residents if doing nebulizer treatment or resident is on high flow oxygen.
• Yes, we have the N95 but not the correct sizes. For example I wear a small and they do not have any. They only have regular sizes.
• We do now but it is too late. I work at Grace Villa and most of them are sick.
• We were informed by our management that N-95 masks are jot required for our LTC home. We are only provided surgical masks. We have enough PPE however time is limited while changing in-between residents.
• Yes we were provided ppe. The nurse from the hospital was telling the other nurse we are changing it too much but we need to change it in between residents. Some of us have not been fitted properly for an N95 so we have to just guess our size. I did get my n95 but to think it’s a little late that we waited till full outbreak to get access to them and not even when our numbers were super high. We just got access to N95 on Dec 4th.
• Management is currently working on getting n95 supplies to us but, many are still working with medical masks as n95s do not fit. Not all sizes are available.
• No we do not get the N95 we were told we do not know how to remove it from our face. They say public health says the surgical masks are better but other PPE are accessible.
• Not until the outbreak occurred yes we have time to change ppe only 1 mask per shift was handed out at the front desk the n95 what was provided on the floor was surgical mask to change every time you’d leave a room from one resident to the next and hand sanitizers were out in the hall along with gowns

 

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