Part 1: March 17-22
At 9:29 a.m. on March 17, a nurse identified in records as Yan Anonymous phoned York Region Public Health to report that six residents at the Markhaven Home for Seniors were sick.
Three days later, swab tests confirmed the worst: the COVID-19 pandemic that was circling the globe had entered the Ontario nursing home amid fears it would “spread as a wildfire.”
And it did.
For two months, the home faced an outbreak its executive director described in a confidential email to health officials as “unprecedented, extremely time-consuming, chaotic and stressful.”
Markhaven wasn’t Canada’s worst-hit nursing home. Nor was it unique. It experienced generally the same problems that plagued a long-term care system ill-prepared for a pandemic.
The nursing home’s management declined to comment, saying only that they had “strictly followed the guidelines mandated by health authorities.”
York Region Public Health and Ontario’s Minister of Long-Term Care also declined interview requests, but a Global News investigation based on public health records and interviews shows what happened.
Supplies of PPE, or personal protective equipment, were a key challenge, according to records and emails obtained through a freedom of information request. Early in the outbreak, Markhaven staff wore plastic garbage bags and white painting suits, while goggles were washed out and re-used. PPE was kept in a locked room, a worker said.
Staffing was another problem. As employees tested positive for COVID-19 or stayed home, the home complained to health officials it was “dealing with staff abandoning their posts” and “fighting tooth and nail to keep staff in the building.”
The documents also reveal tensions between the home’s management and local public health authorities, who struggled to get contact tracing information from the home — and faced criticism from Markhaven that they were not providing enough support.
“We’re regularly having to make critical decisions with very little guidance from authoritative bodies, and we’re doing so with dwindling resources (staff and PPEs),” the home’s executive director Mike Bakewell wrote to health officials.
Two weeks in, the home sounded like it was on the verge of surrender, telling health authorities they “will shut the facility down and transfer the patients out,” according to the notes taken of the call by a public health officer.
By March 29, the home was “requesting more death certificates.” Sadly, they would need them. The worst-hit unit, 2 South, became known among staff as Death Valley.
While nearby nursing homes did not lose a single resident to the virus, 56 Markhaven residents and staff tested positive for COVID-19, and 17 died.
“The picture that the documents paint really is a system which was totally unprepared for the pandemic,” said Jane Meadus, a lawyer who specializes in long-term care.
What happened at Markhaven?
March 17: Outbreak number ‘2270-2020-082’
Chloe Efthyvoulos took care of her mother at home, but a health setback of her own, a fall that broke her ankle, made her realize she couldn’t do it anymore.
She was pleased when she found the Markhaven Home for Seniors, a 96-bed long-term care home that backs onto wooded Paramount Park in Markham, Ont. It wasn’t too big, and she liked the staff.
“I thought this would be a good place,” Efthyvoulos said.
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Run by Markhaven Inc., a charity since 1967, the home received $5.5-million from the Ontario government in 2019, the province said.
Over the years, health inspectors have cited the home 19 times for failing to meet requirements under the Long-Term Care Homes Act, according to the province. In 2017, the last time a comprehensive resident quality inspection report was completed, the home was found to have 19 non-compliance incidents compared to the provincial average of 5.66.
As recently as January, it was found to have failed to comply with infection control and prevention measures.
Markhaven had 60 full-time and 75 part-time staff in 2018, its tax return says. But it had no assistant director of care when the outbreak hit, according to York Region health records that quoted a manager as saying the employee “was fired five months ago due to financial concerns for the facility.”
Efthyvoulos thought the home could have used more staff, but she was content with the care her mother received. The workers loved her mother, and she found the home clean when she visited.
The COVID-19 pandemic was still building steam in Canada on March 12 when a Markhaven resident came down with a cough and fever.
Health records show a second resident developed the same symptoms on March 13, and a third on March 15. On March 16, a fourth resident was coughing and congested.
According to public records, by March 17, the day the home contacted York Region Public Health, six residents and three staff had a mix of coughs, fever, congestion and runny nose.
York Health declared a respiratory outbreak at the facility. It was labelled outbreak 2270-2020-082.
Health officers scheduled an outbreak management team meeting and arranged a courier to pick up swab samples from two residents.
The union representing Markhaven staff questioned why, according to the records, the home waited so long before reporting that residents and staff were sick with COVID-like symptoms, saying that during that time staff were going into rooms unprotected.
March 20: First resident tests positive
On March 20, the Ontario health lab phoned York Region Public Health with the results of a swab test conducted on a Markhaven resident, a 74-year-old woman who had been showing symptoms since March 15.
“Please contact the home and advise them of the result,” Carlos Sebastian, the manager of infectious disease control at York region health, wrote in an email sent at 10:58 a.m.
Forty-five minutes later, the public health unit phoned Markhaven and the home’s director of care, Kevin McKay, listened on speakerphone with executive director Mike Bakewell.
“Told him resident is positive for COVID-19,” the record of the call reads.
The health officers wanted to know who may have brought the virus into the home, and who else had been exposed to it. They asked Markhaven for a copy of its visitor sign-in sheets, going back to early March.
They needed to know who had visited the home, and in particular, who had visited the resident with COVID-19.
They had other questions as well. Had the staff worn PPE when they collected the swab from the resident with the virus? Did any Markhaven staff work at other care homes? Had any travelled in the past two weeks? Had the roommate of the resident who tested positive been swabbed?
A conference call was scheduled for 2:30 p.m. The home wanted to discuss “PPE, staffing pressures, [and] the guidance we are providing re COVID.” The associate medical health officer, Alanna Fitzgerald-Husek, said she would try to join but wrote in an email that “capacity is a bit thin here.”
“They need resources to be sent to them ASAP,” the York health records read, adding the “facility needs PPE as expects to increase number of cases … They want to have extra PPEs as they suspect this will spread as a wildfire.”
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On the conference call were two York region infectious disease control managers, two public health inspectors, Fitzgerald-Husek, and Markhaven’s management. The proper use of PPE came up. According to notes of a public health official, the home was wiping down goggles with disinfectant and using them again, a practice described in the public health documents as “problematic,” while the union representing Markhaven workers said re-using PPE was “absolutely not acceptable.”
Meanwhile, the home was dealing with nervous staff and wanted public health officers to come to speak to staff who were refusing to work.
“It is going to be difficult to reassure the staff and convinced [sic] them to come back. … They don’t know how many will leave as staff are still in shock,” according to health records.
There was also a discussion about private staffing agencies and possibly using them to bolster the workforce during the outbreak. The home ultimately did use at least two staffing agencies.
At 7:45 that night, Markhaven’s executive director sent an email to residents’ families notifying them the pandemic was in the home.
“The health and safety of all residents and staff is our number one priority and we will continue to monitor the situation closely,” he wrote.
March 21: ‘We simply do not have the resources’
Efthyvoulos was terrified when she found out a resident had tested positive for COVID-19, but there wasn’t much she could do.
Visits were suspended due to the outbreak, and because her mother was on the second floor, even window visits were out of the question.
“They’d just tell me, ‘no she’s doing fine, she’s OK, she’s coping,’ but I don’t know,” she said.
Born in what was then Rhodesia, her mother, Loulou Travlos, had immigrated to Canada in 2005 to be closer to her family.
“She knitted all day, knitted baby blankets for her great-grandchildren,” her daughter said.
“She was a family person, always cooking for them, making treats for them.”
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Although she couldn’t see her mother, Efthyvoulos was confident Travlos was in good hands at Markhaven. “I thought they were well-equipped,” she said.
The resident who had tested positive was isolated in her room, and her roommate was moved to a private room. But health officials were still worried the virus could spread, and the roommate had developed a cough.
York Region health officials held a debriefing and scheduled another conference call with Markhaven management to go over the questions they needed answered, according to the public records.
The first concerned the home’s PPE supplies. The home said it had opened its “pandemic box,” and thought it had enough to last two weeks, “depending on the severity of this outbreak.”
But while there was a “large abundance” of gloves, the home “requested more surgical masks and gowns if possible,” according to the public health records.
As they had the day before, the health officers told the home they needed a list of everyone who had been in contact with the resident who had tested positive for COVID-19.
According to health department records, the director of care responded that he “can send us a list, but manpower is the concern here. There is only him alone, no office/admin staff.”
“Suggested the earliest is Monday.”
But that was two days away and Selina Nazim, the region’s COVID manager, explained that she needed the list in order to consult with Public Health Ontario about “next steps,” the records show.
The director of care, McKay, “stated that he doesn’t get paid to come in, this is an independent home,” according to the call notes.
Providing a list of visitors was “a big challenge,” the notes of the call with the care director indicate. “They only have the physical copy of the sign-in sheet from the front door [and] he is not able to differentiate who visited where,” according to the call notes.
As an alternative, it was suggested that York Region Public Health (YRPH) officials come to the home and view security camera footage to identify visitors. The video totalled 500 hours, per camera angle.
“YRPH expressed the priority is to send YRPH the staff and visitor list,” the notes read.
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“Kevin stated that the conversation so far with YRPH has not been helpful to him. There is only one him trying to do damage control and he is unable to complete YRPH’s request.”
“He stated that he has been on the phone with YRPH for 1.5 hours and YRPH is not helpful to him. Kevin wished writer [the public health officer who wrote the entry] and Selina a nice day and hung up.”
Health officials talked it over and called the care director back an hour later to say they appreciated he was “strapped” but again “stressed the importance of getting a list of staff who’d had contact with the resident who had COVID-19.
As part of its investigation, York Health also needed to know where and when Markhaven staff had travelled, whether they had been in contact with anyone who had travelled, and if they worked at any other facilities.
“We are interested to know about the movement of staff between Mar. 1 and Mar. 15 where they may have transmit [sic] illness to the confirmed case,” an internal memo read.
But at 3:08 p.m., Markhaven executive director Bakewell fired back in an email to York Region’s managers of infectious disease control. It was copied to the nursing home’s board chair.
“I have to voice some concerns I have with the level of support we’re receiving from Public Health,” he wrote.
The email said Markhaven’s director of care had spent a long time on the phone “dealing with the investigation into how the virus entered the home.”
“Your staff were insistent that he stop the critical work that he’s doing to go through weeks of visitor sign-in sheets and weeks’ worth of video footage to determine which family members of the resident in question have visited since March 1.”
“I have instructed him to continue the essential work he is doing,” the executive director wrote. “We simply do not have the resources to be conducting [an] investigation of this scope under our current situation,” the email said.
He went on to complain the home had not received “definitive guidance” about what to tell staff who also held jobs at other facilities. He said other homes were telling staff members not to return to work at Markhaven, exacerbating the home’s staffing shortage.
“This obviously concerns me greatly as we are having difficulties getting staff to work in our home, but also because this seems entirely counterintuitive in the fight against the spread of COVID-19 into other LTC [Long-Term Care] homes in the community,” he wrote.
He went on to say that York public health officials had initially said they did not have any PPE supplies, but later said they did — a mixed message he called “alarming.” He said he was also getting conflicting information about whether N95 masks were needed.
“We’re fighting tooth and nail to keep staff in the building, and we will only be able to do that if we are able to give them reliable information. So far we don’t feel we’ve been getting that from Public Health,” the email said.
At 6:30 p.m., York health officials spoke again to the home’s management, saying their priority was “determining acquisition and transmission,” according to notes of the meeting.
“Additional precautions have to be put in place,” added Sebastian, the York Health manager of infectious disease control. “Residents have to stay in their rooms as much as possible. The less contact that residents have with one another, the more protected residents are.”
Everyone working in the home “is going to be wearing a mask,” he continued, adding there should be “avid handwashing.”
York health said it would provide a “reasonable supply” of PPE, as well as training. Why staff weren’t already trained to deal with an outbreak was not addressed in the public health records.
March 22: Staffing crisis
While Markhaven residents were supposed to be confined to their rooms, there was a problem: some were “wanderers,” according to York region health records.
The home said it was working to restrain them.
Two York Health staff went to the facility at 2 p.m. to train the staff. In an email later that day, Markhaven’s executive director called it “a great session” but said he still had “concerns.”
He repeated that while Markhaven staff had been told they were prohibited from working elsewhere, other facilities were not giving the same message. “We need consistent messaging to all parties.”
In addition, he said York health had provided a “new/changed message” about whether N95 masks were necessary. “I’m sure you can imagine staff confidence in us is dwindling rapidly at this point.”
Sebastian put one of those issues to rest. At 10 p.m. he told health officers to contact six Markhaven staff who worked at other facilities and tell them they were not to work until further notice.
The email Markhaven sent to families that night made no reference to the staffing crisis. Rather, it said the home was “finalizing an agreement with a community partner” about additional staff and “supply chains for PPEs” had also been secured.
“As some of you may be aware, on March 14 we saw the first case of a small number of our residents in a variety of home areas who began to exhibit differing symptoms of either cold or flu. “Because the symptoms were inconsistent, it didn’t strictly meet the definition of an outbreak,” it said.
“Out of an abundance of caution, and in light of the current reality, we contacted Public Health. Also out of an abundance of caution, PH decided to declare a respiratory outbreak on March 17. ”
“On March 20 PH contacted the home to say that one of these residents had tested positive for COVID-19. Although we still have just one positive case in the home, PH decided yesterday that changing the outbreak from a respiratory outbreak to a COVID-19 outbreak would give us additional tools to fight the spread of the virus.”
Families would be contacted “if there is any update on your particular loved one,” it said.