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The former Herron seniors residence, which was one of the hardest hit during the first wave of the pandemic, is seen on Feb. 15, 2021 in Montreal.Ryan Remiorz/The Canadian Press

Staff shortage at a Quebec nursing home led its owner to use the same agency workers at two different sites and likely played a role in a coronavirus outbreak that infected 69 people and killed 22 of them, a coroner’s inquest heard Monday.

Coroner Géhane Kamel heard that officials suspected COVID-19 transmission at CHSLD des Moulins, a private long-term care home in Terrebonne, near Montreal, because it shared employees with another home owned by the same firm where an outbreak had started.

Exhibits and testimony show that employees didn’t wear masks properly, high-touch areas weren’t cleaned and double armchairs and the dining room were used without adequate physical distancing.

“There were different points of non-compliance,” testified Nadia Perreault, the head of nursing care for the local health board, CISSS-LAN.

Months after the outbreak ended, there were still staffing problems. CISSS-LAN officials who visited in the fall saw that employees were slow to answer call bells, food wasn’t served on time and families weren’t notified promptly when there were problems with their parents.

“Of course wages in private facilities are lower than in the public sector, which contributes to staffing shortage and instability. Nevertheless we’re concerned about the impact of that shortage on the quality of care,” said an Oct. 27, 2020, letter sent to des Moulins operator Paul Arbec by the office of the Commissioner for Complaints of CISSS-LAN.

About 4,900 residents of Quebec long-term care and retirement homes died during the pandemic last year. The toll led the coroner’s office to mandate Ms. Kamel to hold a public inquest into the fatalities at seven homes, including des Moulins.

Dr. Lynda Thibeault, interim public health director for CISSS-LAN, testified Monday that, in early April, 2020, officials were already dealing with coronavirus infections at another private nursing home in Repentigny, CHSLD Émile McDuff.

They realized that some of the staff at McDuff, in another suburb of Montreal, also worked at des Moulins, which was owned by the same operator, Mr. Arbec’s Groupe-Santé-Arbec Inc.

Dr. Thibeault said employees are the main source of COVID-19 infections in LTC homes. “The residents are often not very mobile, they don’t go outside, so you have to check the employees.”

They asked Groupe-Santé-Arbec for a list of employees who worked at both sites but found it hard to get the information because some weren’t regular staff, but came from an agency. “We realized there was workforce mobility, which wasn’t recommended,” Dr. Thibeault said.

Four employees who showed symptoms tested positive so they expanded testing and by April 14 there were 29 confirmed cases among workers and residents, according to a CISSS-LAN report tabled at the inquiry.

The first identified case was an auxiliary nurse who worked the first 48 hours she was contagious, wearing a mask only during the second day, the report said.

The report added that staffers weren’t adequately trained in using personal protective equipment, they didn’t sanitize their hands properly and residents with cognitive problems wandered in the hallways.

The document said 45 residents at the 108-bed facility and 24 employees contracted the coronavirus, leading to 22 deaths.

At the time, Quebec recommended, but didn’t ban staffers from working at multiple facilities. Even so, Dr. Thibeault said transmission could have been curtailed if all precautions were strictly followed. “We were at the start at the pandemic; were people properly trained at the beginning?”

It was up to LTC homes to alert the health board if they struggled, but private facilities don’t readily ask for help, she said. “There was an evolution. In the beginning, we had to go seek them.”

Just before the pandemic struck, des Moulins was visited by provincial inspectors who later told Stéphane Mercier, CISSS-LAN’s director of quality, that the home relied too much on agency staff who were less invested in the care of the residents. “We agreed it was worrisome,” Mr. Mercier testified.

Patrick Martin-Ménard, a lawyer representing the family of deceased resident Lucille Gauthier, asked about a 2019 report from Accreditation Canada, an agency that audits nursing homes. The report lauded the prevention of infections at Mr. Arbec’s facilities. “Disinfection is done with rigour,” it said.

Mr. Mercier said Accreditation Canada reports tend to “use a tone that’s more encouraging than accusatory.”

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