Ombudsman Investigation Finds Extendicare Parkside was Unprepared for COVID-19 Outbreak

Today, the Speaker of the Legislative Assembly tabled a report by Ombudsman Mary McFadyen titled Caring in Crisis: An investigation into the response to the COVID-19 outbreak at Extendicare Parkside. The report looks at how the outbreak happened, how Extendicare (Canada) Inc. managed its Parkside facility’s preparations for handling the pandemic, and whether the Saskatchewan Health Authority and the Ministry of Health provided it with reasonable oversight and support.

The report describes how COVID-19 gained a hold in the facility before Extendicare realized it. As of November 20, 2020, when the outbreak was declared, Extendicare only knew of two positive cases, a resident and an employee. The resident had already died. Contact tracing would later show that there were actually already 13 residents and 12 employees with COVID-19 symptoms who would later test positive. From there, the number of cases and deaths continued to grow.

McFadyen said, “This was a tragedy. 194 out of 198 residents got COVID-19 and 39 of them died of it. Three others who got it died of other causes. 132 Parkside staff also got COVID-19. It is important for residents and their families to know what happened. I hope our recommendations will help to prevent something like this from happening again.”
McFadyen said, “We focused our investigation on five areas: physical layout and limitations, pandemic planning and management, the supply and use of procedure masks, limiting the spread of COVID-19 from resident to resident, and staff and staffing.”

She found that the physical limitations of the Parkside building were well-known by Extendicare, the Authority and the Ministry. As early as March 2020, the Authority and Extendicare were aware that Parkside would be in serious trouble if it were to have a major COVID-19 outbreak – but instead of reducing Parkside’s population, so no more than two residents shared a room, the focus was on keeping a few rooms vacant to isolate COVID-19 positive residents. This was a mistake.

Given its physical limitations, McFadyen said it was vital for Parkside to prevent an outbreak – but it was badly unprepared:

  • It was not consistently screening staff for symptoms and failed to ensure staff were taking required precautions like social distancing and wearing masks during breaks.
  • Authority and Extendicare officials both thought Parkside did not have to comply with the Authority’s masking guidelines (even though it did have to). Instead of giving staff at least four new masks per shift, Parkside gave one mask per shift and a paper bag to store it in on breaks. The Authority’s ‘hands off’ approach coupled with Extendicare’s ‘back off’ approach made collaboration on other issues more difficult.
  • Parkside’s pandemic plan was to isolate positive residents in a hallway on its north wing. Instead, it isolated the first few positive residents in its main wing where they had been staying. By the time it decided to move positive residents as planned, it had so many cases it needed to convert its entire north wing into a COVID-19 wing. Its staff were not equipped to safely move so many residents at once. Positive residents were moved simultaneously with non-positive residents. Not all of them were masked and rooms were not fully disinfected between moves.
  • Parkside did not have an outbreak staff contingency plan to replace staff who had to self-isolate. This created a staffing crisis within the first few days of the outbreak. Because it is not an Authority affiliate, it also could not directly access the Authority’s staff. This was one of the key reasons the Authority had to take over Parkside and manage the outbreak.
    Since June 2020, Extendicare lobbied the Ministry to bring on-site rapid testing to its Saskatchewan homes. The Ministry said it did not have enough resources and that the measures in place were effective, but it did not know that Parkside was not properly following these measures. Rapid testing was implemented on December 8, 2020 at Parkside and in January 2021 throughout facilities in the province, but this was too late for Parkside residents.

As of November 6, 2020, a public health order required long-term care residents to wear masks when not in their rooms, unless they were eating or had a medical condition or cognitive impairment that would prevent them from doing so, but Extendicare and Authority officials were not aware of this requirement until late December 2020.
McFadyen also found that Extendicare has not done a critical incident review, which is required whenever there is a serious, adverse health event, including loss of life. The purpose of these reviews is to prevent similar errors in the future.

Based on her findings, McFadyen recommended that Extendicare: apologize to the families of the Parkside residents who passed away as a result of the outbreak, and to all the other residents whose lives were disrupted; that it collaborate with the Authority to conduct a critical incident review of the outbreak at Parkside, that it ensure its administrators and staff comply with its own rules and the rules laid out by the Ministry of Health and the Authority; and that it ensure it has resources on site so its staff will be able to comply with all relevant infection prevention and control management.

The investigation found that the Authority generally gave Parkside reasonable support during the pandemic and outbreak; however, there were areas where oversight was lacking. McFadyen recommended that the Saskatchewan Health Authority immediately stop allowing 4-bed rooms in long-term care facilities; that it update its agreement with long-term care home operators and ensure they comply with its care-related policies, standards and practices; that it conduct detailed annual reviews of all long-term care homes to ensure they are following its care standards and report publicly on each home’s level of compliance, and that it also ensure its communicable disease prevention and control management standards and practices are being followed consistently, including completing inspections of all long-term care homes at least once a year.

McFadyen did not make any recommendations to the Ministry of Health, because it has positioned itself to have no responsibility for long-term care home operations. With total governance and spending control over the entire health system, the Ministry needs to fully implement recommendation 19 made in her 2015 Taking Care report. She said, “We strongly encourage the Ministry to make meaningful and lasting systemic and structural improvements to Saskatchewan’s long-term care system so that something like this does not happen again.”
The reports and related information are available at The Ombudsman is an officer of the Legislative Assembly who operates under The Ombudsman Act, 2012 and The Public Interest Disclosure Act. Her Office promotes and protects fairness and integrity in the design and delivery of government services.

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Media Contact: Leila Dueck
Phone: 306-787-7369


Caring In Crisis Full Report (application/pdf, 814.18 Kb)

Caring In Crisis Summary (application/pdf, 162.02 Kb)

Caring In Crisis Timeline (application/pdf, 922.32 Kb)

Caring In Crisis Media Conference (application/pdf, 136.85 Kb)