Hamilton retirement home emptied due to COVID-19 outbreak — but a sick resident was left behind

A man with COVID-19 was left behind Friday when the entire Rosslyn Retirement Residence in Hamilton was emptied because an outbreak of the illness had infected dozens of other residents and staff. 

The mistake wasn't discovered until the next evening, after the man's family had repeatedly insisted he hadn't been transferred to hospital with the others and was still in the building.

The man was finally found, alone in his room, around 7:30 p.m. Saturday.

The mistake happened amid a crisis that left the home without any of its regular staff — and the health-care workers who were called in to help didn't have a master list of residents.

"This was clearly not something anybody would have intended to do," said Winnie Doyle, executive vice-president of clinical operations at St. Joseph's Healthcare Hamilton, a local hospital that helped organize the transfer of Rosslyn residents and where many of them ended up. "It was a mistake and I heard from the family on Saturday that they were very concerned." 

Doyle said she immediately called the home, where an operator reached security, who then found the man in his room.

The family had been "trying to contact the home all day and, in fact, I think a family member had gone to the home at one point," she said.

Doyle would not release much information about the resident, citing privacy, but said he was "alert" when he was found and has since been transferred to the COVID-19 unit at St. Joe's Charlton Campus, where he's in stable condition.

In response to questions about his condition following hours without care, she said the man had access to a washroom, though she could not verify whether he had access to medication.

Dave Thompson, a Hamilton paramedic superintendent, said he was aware of the incident.

"We did respond back there for a patient on Saturday," he said, before directing any further questions to public health, Hamilton's emergency operations centre and Rosslyn.

The home did not immediately respond to phone messages or an email requesting comment.

No master list of residents

St. Joe's is one of two Hamilton hospitals where 52 Rosslyn residents were transferred Friday as the home was cleared.

"The home wasn't meeting the safety standards that needed to be met," said Doyle, who described the number of individuals with COVID as "a very serious concern."

A statement from St. Joe's described the transfer of residents as a "co-ordinated effort" involving Hamilton EMS, police, hospitals and the home.

It began around 4:45 p.m. Friday when three ambulances pulled up outside the home and paramedics covered head-to-toe in protective gear rolled stretchers inside.

The last patient arrived at St. Joe's roughly eight hours later, at 12:50 a.m.

Staff from St. Joe's left the Rosslyn around 1:30 a.m., said Doyle, who noted it's her understanding the home's owner and security staff were still on site at that time.

However, somewhere in the transfer process — and despite a final sweep of the facility — the man was missed.

Doyle pointed to several factors that may have led to the mistake, the main one being that the home, which has struggled with staffing amid the outbreak, did not have any regular employees working there by mid-morning Friday, as many of them had been diagnosed with the virus and were in self-isolation.

"There wasn't one regular member of the staff working in the home," she said.

The situation was made even more difficult by another major issue — there was no up-to-date master list of residents at the Rosslyn, leaving the LHIN and hospital staff helping with the transfer in the dark, according to Doyle.

Staff tried to put together resident records as best they could, but there was another challenge.

"We had been told by the home that the individual had been transferred to the hospital earlier in the week," said Doyle.

An outbreak was declared at the Rosslyn on May 10.

There were 63 resident cases at the 64-unit home as of Tuesday, according to public health.

Twenty staff members have also tested positive. Two residents have died.

St. Joe's staff 'extremely distraught'

Doyle said when the St. Joe's team found out about the man who was left behind they were "extremely distraught." 

"These are people who … are exceptional clinicians and practitioners with extremely high standards and this was nothing but extremely distressing to them once we were aware this situation had occurred," she said.

The hospital is investigating what went wrong.

"It's a situation everybody would want to avoid," said Doyle. "We've absolutely had some learning from this."

St. Joe's is also working on a list of recommendations, she said, describing a master list of all residents as "essential" for any future transfers, as well as a search that covers "all of the spaces in the home."

Ultimately, the owner and operator of a home are responsible for how it's run, said Doyle.

But, "once you get into this sort of a crisis situation ... we need to be very clear so everybody fully understands their accountability and responsibility."