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In the confusion that swept through Manoir Liverpool after the Quebec retirement home was hit by COVID-19 last year, much of the personnel went missing, residents weren’t properly fed and medications no longer were properly dispensed, documents filed at a coroner’s inquest allege.

Amid the chaos created by a staff shortage and dying COVID-19 patients being sent to hospital, one social worker recalled seeing tables covered with lost objects from Manoir Liverpool’s residents: clothing, hearing aids, adaptive shoes.

Those details were made public Monday at the inquiry presided over by coroner Géhane Kamel into deaths in Quebec’s long-term care and retirement homes during the first wave of the pandemic.

Private seniors’ homes were not as badly hit as LTC homes where thousands of elderly people died. However, Monday’s proceedings heard of familiar shortcomings in those facilities: a chronic lack of employees, vulnerable people left in squalid conditions and difficulties by local officials to identify and remedy those problems.

The recollections from the social worker, whose name is under a publication ban, were outlined in an transcript tabled at the inquest. Her observations mirror the findings of an administrative investigation into Manoir Liverpool ordered by the regional health authority, known as the CISSS de Chaudière-Appalaches.

A summary of the investigation said care plans were inadequate, residents weren’t bathed for weeks and were administered expired medications.

Located in Lévis, south of Quebec City, Manoir Liverpool housed 128 people; 48 in a retirement home and the rest in assisted-living quarters.

An outbreak started on March 24. By April 9, Manoir Liverpool was asking the CISSS for help because it had one quarter of its orderlies left, and one supervisor out of six.

“People who caught COVID were transferred to Hôtel-Dieu [hospital] in Lévis and died. Housekeeping was neglected and residents’ personal belongings were lost,” the social worker said.

Even before the pandemic, she said, toilets were grimy, grab bars had fecal stains, bathroom floors were sticky and visiting relatives needed to bring wipes and mops to clean their parents’ rooms.

During the outbreak, she said she witnessed errors in feeding elderly residents. For example, she said: “I had a lady who couldn’t have rice because she might choke. There was rice on her plate.” Others who couldn’t digest lactose were fed dairy products, those who needed pureed food received regular meals.

Medications were not dispensed or were given on the wrong day, she added. “I found medications in people’s bedrooms that didn’t belong there.”

David Lacombe, a CISSS manager who was dispatched to help, said his first move upon arriving on April 11 was to set up sanitary stations where staff could dispose of soiled protective gear.

Considering it was weeks into the pandemic, “Isn’t it a bit late to set that up?” asked Jacques Ramsay, another coroner attending the inquest.

“I would have done it earlier but I only arrived on April 11,” Mr. Lacombe replied.

Officials at the CISSS realized the full scope of the problem at the end of April when Radio-Canada reported about the conditions at Manoir Liverpool.

Daniel Paré, who was the CISSS’ chief executive at the time, testified that he hadn’t been notified of previous problems at the facility. There had been seven complaints in the past three years but “it wasn’t about mistreatment or negligence,” said Mr. Paré, who now heads Quebec’s COVID-19 vaccination campaign.

Ms. Kamel noted that between 2016 and 2020, the CISSS had mandated a series of action plans for Manoir Liverpool because of its shortcomings. “It certainly wasn’t a five-star place,” she said.

One root cause for Manoir Liverpool’s troubles was that it tried to cater to three different clienteles, testified Valérie Lapointe, director of quality and performance for the CISSS.

She said the home had trouble juggling the needs of autonomous seniors, seniors with dementia who wandered and younger residents with physical impairments.

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