This is the second instalment in a series looking at what was known about the state of long-term care in Ontario prior to the pandemic. Read Part 1 here; watch for Part 3 tomorrow.
The COVID-19 pandemic has ravaged Ontario’s long-term-care homes. The majority of the province’s pandemic deaths have occurred in these institutions, where conditions became so dire the province was forced to call on the Canadian Armed Forces for desperately needed help. Those soldiers, in turn, observed conditions so appalling that a report was transmitted back to National Defence headquarters in Ottawa — a report so bleak that Premier Doug Ford has said reading it was the hardest moment of his time in office. The provincial government has pledged an independent commission to look into the LTC system; the provincial ombudsman has begun its own investigation. But Ontario’s LTC system has been extensively studied for years. The problems that made the pandemic so devastating had not been unknown. This week, TVO.org will catalogue just a few of the reports, papers, and other warnings regarding the state of our LTC system that were issued before the pandemic — and that we could have acted on. Today: Doris Grinspun, CEO of the Registered Nurses’ Association of Ontario, an organization that has published numerous reports on LTC homes over the years.
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Matt Gurney: Doris, obviously, thanks for doing this. I just want to start by mentioning something. This is the second of these interviews I’ve done. The first one, when I got in touch, I said I wanted to talk to them about their long-term-care report, and they asked, which one? We’ve done so many. And, with you guys, I got in touch, and I said, “Hey, I found the briefing memo you guys prepared to present at Queen’s Park in 2018,” and your communications staff were able to instantly go, oh, well, if you’re interested in that, look at all the other ones we have. The entire point of this series was to show how much was already out there — and it’s more than I’d realized.
Doris Grinspun: All this information is out there. For years. Let me ask you something. What’s happening on July 31, 2020?
Gurney: [awkward pause] I have no idea.
Grinspun: Exactly. No one does. I doubt the premier does. Nor does, likely, most of the media or many nurses or doctors. Or anybody else. But it’s important. And Minister of Long-Term Care Merrilee Fullerton knows but keeps it quiet. Let me explain. There was a public inquest into the nurse, I don’t say her name, who murdered eight patients. RNAO called for that inquest. There was some opposition to that, but we said, no stone unturned — the premier says that, too, now! But we wanted a full inquest into the long-term-care system. Not just into the murders, but into the full system. We negotiated with the Kathleen Wynne government, and we got that — the inquest took a full look at the system. And one of the recommendations from that inquest is that, by July 31, 2020, Minister Fullerton has to table, in the legislature, a report on the adequacy of regulated staffing in nursing homes.
Gurney: Wow. What an incredible quirk of timing.
Grinspun: Bingo, Matt. Bingo. So now you know what we’re after. I don’t want more inquiries or commissions. It’s a waste of money and time. Here’s what I think happens with all of those things. Because I have asked for two. I was there for SARS; we asked for a report. And then after the murders. But the government of the day washes their hands and says, “Sorry, can’t comment. There’s an inquest going on.” The opposition parties score points. And then nothing happens, because everybody forgets. Too much time passes, and everybody forgets — time and again and again and again. So people are asking me what I want and what my organization wants. We want the results on July 31. That’s all I want. I want to see what staffing level Ontario will recommend. And what’s the money behind that staffing? Will the for-profit and public systems be held to the same staffing standard? That’s what I want. I want to know that by the end of next month.
The system is a disgrace to residents, who don’t have the power or the voice or capacity to advocate for themselves. It’s a disgrace for the families, and now, because of the pandemic, the families are locked out. They can’t go in and advocate for their loved ones. They can’t see what’s going on. And third, it’s a disgrace for the staff. I know them. I know the executive directors and operators. Everyone wants to do good work. But it’s impossible in this system.
Gurney: Let’s talk a bit about that system. Right now, it’s getting attention because of the pandemic. A few years ago, it was getting attention because of the murders. But you’ve been watching this for a while. Your organization has been writing warnings about it for years. I know that you yourself have talked about it. The problems we’re seeing in the system aren’t new, and they were being talked about. But people didn’t listen — or at least they didn’t retain what they heard.
Grinspun: The system is a disaster. It’s always been a disaster, as long as I’ve been involved in it. Nursing and LTC homes are funded with a formula that provides 2.9 to 3.1 hours of care per resident. That’s the average. Some patients are very high-need and get more than that, but the formula puts enough nurses and personal-support workers to give three hours of care per patient per day. But it’s like people forget that a day has 24 hours. We’re asking for four hours, and people say, “Really, where are you going to get the money for that? How can we afford that? Would we ask that in a hospital?”
What’s wrong with us? These patients and residents are severely compromised. They have incredibly complex care needs. We’re asking for 0.8 hours of a registered nurse’s time per patient. That’s 48 minutes per day. In that time, they can check the resident, see what’s going on, assess their condition and if it’s changing. We’re saying, give us one hour — again, one hour in a day — of a registered practical nurse. And 2.2 hours, a day, of PSW. Is that too much to ask? We don’t think it is.
People who haven’t experienced it don’t know how long it takes to get someone with dementia dressed and then take them in a wheelchair to an elevator and then take them outside for fresh air. They don’t know how many minutes it takes to take someone who has mobility problems and help them use a toilet, which they’ll need to do many times over a day. They don’t know how long it can take to feed someone a meal. We’re asking for an extra hour a day, and we don’t need another report to tell us why we need that.
Gurney: Yeah. That’s why I’m doing this project. The pandemic was obviously a bolt from the blue. But the issues were pretty generally well understood for anyone who cared to look.
Grinspun: I came to Canada in 1989. I was at Mount Sinai Hospital. We were signing agreements with specific nursing homes to send patients from a unit we had to nursing homes without going through an emergency room. It was a fantastic program, and it helped avoid dehydration, confusion, etc. I went myself, and this is in the early 1990s, to visit all the nursing homes. I wanted to see them myself. You walk in, and you can see immediately if it’s a good place or a bad place. And it’s all how the patients look. Do they look at you, or are they all withdrawn? You knew right away.
Gurney: I wrote recently at TVO.org about exactly that. I used to go into a lot of LTC homes, and you could spot the good ones and the bad ones right away. And some of the bad ones were really bad. You’d smell it when you went in.
Grinspun: Yes. I remember one home — I’m not going to mention the name, because this was almost 30 years ago, and maybe it’s much better now — but I went in, and I saw the residents, and the diapers, and I said, never. Over my dead body. We will not transfer a patient here. I moved to RNAO in 1996, and, when I talk with my team here, we know that these problems go all the way back to Bob Rae. And continued under Mike Harris, and then Dalton McGuinty and Kathleen Wynne and now Doug Ford. It just hasn’t stopped. In 2003, George Smitherman, he was the health minister, he cried and he promised a revolution in the long-term-care homes. But nothing happened. Every premier, we tell them what the problems are. Every premier, they say they’ll take it seriously. But none of them give us anything.
The exception was Dalton, I guess. He said they’d get us 75 extra nurse practitioners. But that turned into 60, and then it stopped. And I’m still pushing for that. Every nursing home should have a nurse practitioner, and the ones that do are doing better in this emergency. They’re physically there for 12 hours. The clinical care is better. People ask me, how can we pay for more? By keeping these people out of emergency rooms. That’s how we pay for it. We save money on hospital admissions by doing better care in the nursing homes. And guess what? It also gives the patients a better quality of life and makes the families happier and more satisfied with the standard of care. How much is that worth?
Gurney: Doris, you’re telling me here about decades of warnings here. But when the pandemic hit, people were surprised. Why do you think that’s the case?
Grinspun: We had information, but what we needed was an uprising. We needed an uproar. We needed people up in arms. We need the media to play a critical role. But, when bad things happen, we need to correctly identify what the issue is. It’s not this home or that home was badly run. It’s systemic. It’s funding. It’s staffing. In this pandemic, our staff were telling me which homes there were problems. We had staff calling me at home begging for help. And we got those requests going, but there were delays in the system, and then we had public health getting involved and the army coming in. But we knew. We knew before what the problems were, and we were trying to cope during this pandemic. But the system is slow.
Gurney: And when the pandemic hit, you saw all the early attention on the hospitals, but you would have known immediately that the LTC homes were going to be a problem. But the public didn’t notice for weeks.
Grinspun: We had meetings right away, and memos and conferences. Very early on. We were saying early in March that we needed universal masking. But we didn’t have enough masks. Even though nursing homes have the most vulnerable people. Hospitals moved to mandatory masking. But they got the masks. We didn’t. We didn’t have the PPE. In Kingston, the nursing homes got PPE. And they were able to do much better. But, in Toronto, we struggled. Other countries did better. Kingson did better. Why? They had PPE for the nursing-home staff.
Look at what happened. The pandemic hit, and the hospitals didn’t crumble. They held. But the LTCs struggled, and the correctional facilities. Even now, we’re hearing reports about migrant farm workers. The hospitals got the attention and the PPE and the funding, and they didn’t crumble. The places that didn’t get the PPE struggled. And we had the vulnerable people.
Gurney: We are going to have to address all of this eventually. But we’re still in this emergency now. What do you need immediately?
Grinspun: July 31! That’s when we need a plan. We need a commitment now to four hours of care a day, like I told you earlier. We need PPE. We knew all this before. We did before the pandemic. Let this be the government that finally decides to fix this. Don’t study it. Fix it. They know what they have to do.
This interview has been condensed and edited for length and clarity.