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Bernadette Cheung poses for a photograph outside Little Mountain Place, where her grandmother who passed away was a resident, in Vancouver, on Thursday, January 7, 2021.

DARRYL DYCK/The Canadian Press

There was a lack of understanding about infection control measures during a COVID-19 outbreak that killed 41 seniors at Vancouver’s Little Mountain Place long-term care home, and the problems were compounded by a staff shortage as dozens of workers fell ill from the virus, an internal report has found.

The Vancouver Coastal Health (VCH) inspection report, obtained by The Globe and Mail through a Freedom of Information request, was produced in response to complaints from multiple families about the facility’s management of the outbreak.

The report is light on details, and families continue to call for accountability and answers about why the pandemic took such a heavy toll at this care home. The family of one victim said the report makes clear that the deaths did not have to happen.

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A staff member of Little Mountain Place tested positive for COVID-19 on Nov. 20, but families of the residents were initially told the exposure posed a minimal risk to their loved ones. The next day, a resident tested positive, and an outbreak was declared on Nov. 22. Almost all the residents – 99 out of 112 – contracted the virus, along with 71 members of the staff.

Staff levels were sufficient prior to the outbreak, according to the review, but with so many workers off sick, the home no longer met normal care requirements, much less the additional demands required to care for residents as the virus spread through the population.

“As the staffing complement became increasingly affected as result of the virus, staffing levels fell below [the facility’s] baseline, which temporarily affected the daily operations of the facility,” the report found.

Infection control procedures at Little Mountain Place were also found to be out of compliance with regulatory requirements. “It was identified that the facility household team did not fully comprehend or implement the intended infection control/enhanced cleaning measures appropriately.”

The health authority sent a specialized infection control cleaning team to the facility on Dec. 13, and a follow-up inspection late in January concluded that Little Mountain Place now meets the health authority’s requirements.

Parb Bains, whose 89-year-old grandmother died of COVID-19 at the care home on Dec. 20, said the findings confirm some of the concerns raised by the families of residents about staffing levels, but it falls short of the answers her family wants.

“My grandmother didn’t have to die,” Ms. Bains said in an interview Monday evening.

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The care home assured families that all infection control measures had been implemented, she said. “So obviously, they weren’t.” She wants to know why the health authority waited so long to offer assistance.

“That’s just ridiculous that they did education for appropriate cleaning measures like that … almost nine months after the pandemic started in Canada. And they knew that seniors were being targeted, and were most at risk, so why weren’t these measures taken at the beginning? It could have prevented so many deaths,” Ms. Bains said.

Bernadette Cheung’s grandmother died of COVID-19 the same day as Ms. Bains’s grandmother.

She said the report lacked details, and offers no plan for the future. “The piece that I’m missing still, is management taking accountability for these kinds of weaknesses?” she asked. “What about all those lives that were lost? It’s great that they’re now in compliance based on the specifics of this report, but the fact is 41 people still died, so what are they going to do about that part?”

The executive director of the facility, Angela Millar, resigned earlier this year, and Vancouver Coastal Health has placed the care home under administration. Officials from the health authority have not commented on the findings of their review.

In a letter to families dated March 26, Michelle Preston, the health authority’s regional director for patient care quality, defended her agency’s conduct. “VCH responded appropriately to address the facility’s infection prevention and control needs during the outbreak once engaged to do so by [Little Mountain Place].”

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Isobel Mackenzie, the B.C. Seniors Advocate, said the internal report helps identify issues related to the facility’s license. “But to understand the extraordinary impact of this outbreak, we need to look beyond that narrow scope.” She is conducting an independent review into the circumstances in the B.C. care homes with the worst outcomes during the pandemic, “and Little Mountain Place is clearly a part of that.”

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