How nursing home staff springs to action when a resident tests positive for COVID-19

Melanie Smith, registered nurse and assistant director of care at the Henley Place long-term-care home in London, Ont., pumps disinfectant onto her hands and quickly finds a sink for washing, singing the Happy Birthday song in her head.

Smith and another nurse have just inserted a tiny swab inside the nose of an elderly resident, isolated in her private room, where a stuffed teddy bear sits on the lounge chair by her bed.

She has a fever of 38.8 C and earlier this morning, Friday, March 27, nurses heard crackling in her lungs.

These are the symptoms of COVID-19.

The swab is now sealed in a vial, which is encased in a security bag. Smith grabs the bag and her purse. She races across the parking lot to her Hyundai Tuscon SUV and drives five minutes to the public health lab, where staff are waiting.

As COVID-19 surges through long-term-care homes across North America, Italy, Spain and France, killing elderly residents and infecting workers, there’s no drama in saying that the contents of that delicate swab could be the stuff of nightmares.

In Ontario, the virus has killed at least 40 elderly residents of nursing or retirement homes, with staff infected, too. The Canadian Union of Public Employees of Ontario said 26 workers in 11 homes have tested positive.

In Toronto’s Seven Oaks long-term-care home, at least eight people have died, and Bobcaygeon’s Pinecrest nursing home recorded its 22nd death this weekend.

Back in London, on the warming spring morning of March 27, the answer to all those fears is now in the hands of the lab technicians. Results could take 48 hours.

Smith’s nurse brain focuses on facts, and she returns to Henley Place, where 29 other residents on the ground-floor Medway unit need to get on with their day. The residents the sick woman had interacted with are already isolated in their rooms.

Crystal Graham’s shift ends at 2 p.m. She is a personal support worker, 34 years old, with a mother who works in a different nursing home, a 12-year-old daughter and a grandfather who relies on her care. The administrators here hired her when Henley Place opened nine years ago, and she never left. The woman with the fever is her resident.

Graham noticed that something was wrong the day before, on Thursday, after she arrived for her 6 a.m. shift and passed the COVID-19 screening questions at the front door. Graham’s temperature was normal, at 36.2 C. And no, she had not been exposed to anyone with symptoms.

Graham changes into her scrubs, pulls her hair into a topknot and walks into the woman’s room, expecting their usual morning chatter. The woman is still asleep. When she awakens, her eyes stare beyond Graham. Her body feels heavy when Graham tries to change her clothes.

By the time breakfast finishes, Graham knows something is off. The nurses come and diagnose a fever. They suit up in personal protective equipment. In medical shorthand, it’s PPE — the surgical masks, gloves and gowns, shields against the unknown. They keep the woman isolated in her single room, one of the blessings of newer homes, where residents are not housed in small ward rooms of four, like so many homes that have had COVID-19 outbreaks.

When Graham’s shift ends, she goes home and stays in her room.

The next night Kelly Kummerfield, Henley’s administrator, watches the news, all about COVID-19.

Her cellphone rings at 6:14 p.m. It is Henley’s director of care.

When the call ends, Kummerfield stops for a moment. She’s been a nurse for 30 years. Worked through SARS. But this coronavirus, it feels different. She inhales and calls Jill Knowlton, chief operating officer of Primacare Living Solutions, the Toronto-based company that owns Henley Place and homes in St. Catharines and Brampton.

“We have our first positive case,” Kummerfield says. They pause. Knowlton says, “OK. All right. Here is what you are going to do.” She tells her to call the managers and organize a meeting at Henley.

Melanie Smith stands over her stove, stirring a pot of cheeseburger soup, when the phone rings. It’s Kummerfield, and her voice sounds official.

“Melanie, I need to inform you that we have had a positive result on the nasopharyngeal swab.”

Smith feels her body turn cold. She doesn’t speak. Kummerfield says, “I need your help.”

Smith turns the burner setting to low and tells her partner she has to leave. She packs an overnight bag with a uniform, an extra set of clothes and a small bag with a toothbrush and drives 45 minutes to work.

Smith walks into Kummerfield’s office. Four others are in the room, so Smith and Kummerfield don’t speak. They don’t have to. Nurses spend so much time hidden behind surgical masks they develop what Smith calls “eye emotion.” From the look Kummerfield gives Smith, she knows they are going to help each other get through the night.

Over the speakerphone, Knowlton sets out the next steps. Full PPE for all staff in the Medway unit. Make calls to the employees and families, starting with calling Medway staff who worked Friday. Tell them staff who work in Medway cannot work anywhere else in the home. Nor can they work in other nursing homes. No mingling of residents. Henley is on lockdown.

Crystal Graham is at home alone, watching Disney Plus at 10 p.m., when a private number pops up on her cellphone screen. “Here we go,” she thinks. It is a human resources worker. “We have bad news…” the worker begins.

As he speaks, the room fades to the image of her grandfather’s face. She visits him every week, bathes him and helps him live in his home. “What if I gave it to him?” she thinks.

Graham hangs up and dials Melanie Smith’s cell. Smith is the assistant director of care, a position of authority but still front line. Graham wants details. She asks about health and possible hospice care for the woman with COVID-19. “She’s my resident,” Graham says.

Smith lists the infection protocols and tells her the home has a good supply of PPE. In the Medway unit, she says, staff will wear surgical masks, gowns, gloves and goggles. Supplies will be easily accessed in the hallways and replenished. Before staff enter a resident’s room, they will dress in fresh PPE and then remove it in the doorway when leaving.

As Graham listens, her other cellphone flashes with text messages from personal support workers in the unit.

“Did you get the call?” they ask.

They exchange texts about exposure. About passing it to young children at home. Graham keeps thinking about stories in the news that said the virus can be carried for days without symptoms.

“Maybe we have it already,” the texts say.

At Henley Place on Saturday night, a nurse and a personal support worker wrapped in PPE watch over the woman with COVID-19.

She had been stable during the day but late in the evening she grew hotter and lethargic. Staff speak with her family and doctor. An ambulance arrives and takes her to the hospital.

At midnight, Smith stops making calls to Medway staff and families. At 1:30 a.m., now Sunday, she drives to a colleague’s home in London, where a glass of cabernet seems like a good way to ease the mind into sleep. Work begins again at 6:30 a.m.

When the COVID-19 outbreak hit Ontario, Kummerfield promised her staff she would tell them immediately if it arrived at Henley Place. On Sunday, managers each visit a unit within Henley to break the news.

“It’s not your unit but I’m letting you know that we have our first case,” Kummerfield says to staff gathered at a nursing station. She notices tears welling up in some workers’ eyes.

“I know you are scared. It’s OK to be scared. I am scared too. But we’ve been trained on how to do this. What happens now is, we carry on.”

Crystal Graham spends most of Sunday on her phone, playing the role of straight-shooting therapist for worried co-workers. Some are afraid and didn’t go to work. They want to be tested, although public health has said testing isn’t needed unless symptoms arise.

Graham talks about her conversation with Smith, about the infection control protocols, and says the home has a steady supply of PPE. She understands their reluctance, but she thinks of the residents in Medway, like the man whose anxiety is so extreme he’s afraid of his shadow and the darkness of nightfall. He likes her, and they laugh together.

On Monday, the home asks Graham to fill an empty slot on the afternoon shift. She says yes, adapting to the new protocols, dressing in fresh PPE when entering and leaving every room.

After her day shift on Tuesday, Graham drives home, undresses inside the front door, showers and disinfects her kitchen counter with Clorox bleach spray.

She cooks pasta for dinner and eats alone in her room. Her mind churns. The fear of the invisible enemy. Exhaustion. The fresh pain behind her ears from the tight elastic bands on the face masks and the hard plastic of the goggles. The expressions of workers from units untouched by COVID, looking at her like she’s infectious.

She goes to sleep at 8:30.

On Wednesday, the residents settle in their rooms. A fruit plate arrives. Staff gather in an isolated break room and for a moment everything seems normal. Melanie Smith hadn’t planned it, but the words came fast, like a general to soldiers.

“You know what, guys, we’ve got this,” she says. “You guys are all heroes and you need to understand that your courage is something that most people will never understand. I know you are scared. We all are. I am, and we all have reasons to feel that way but at the end of the day you are here.”

Under COVID-19 protocols, nobody hugs. Some cry. Then a male personal support worker claps his hands together, like he is in a huddle in a football game, and says, “OK, now break!”

Everyone goes back to work.

On March 30, Ontario’s medical officer of health made more tests available to long-term-care homes, and two additional residents in the Medway unit subsequently tested positive. Both men are eating full meals and have no fever, Knowlton says.

Four workers who spent time with the first COVID-positive resident in the hours before her diagnosis have been told to isolate at home.

The resident in hospital, who loves to laugh when she awakens in the morning, is in palliative care.