An outbreak of COVID-19 at the Rosslyn Retirement Residence in Hamilton, Ontario resulted in dozens of residents and staff being evacuated, with one resident being forgotten and left behind at the home on Friday, according to CBC.
The man's family had to repeatedly insist that he wasn't at the hospital to which the other residents had been transferred.
It wasn't until Saturday evening before the mistake was discovered and it became understood that the man was still at the Rosslyn Retirement Residence.
It was around 7:30 p.m. when the man was discovered back at the home, alone in his room. He was the only one there.
The outbreak caused regular staff to become infected and others to self-isolate. As such, the usual staff was not on hand to conduct the evacuation.
Those who handled the evacuation of residents were not familiar with the residence, and did not have a master list of those who were being cared for at the home.
Those health-care workers who were called into help were unaware of how many people were present at the time of the crisis. Additionally, they were under the impression that the man who was eventually left behind had previously been transferred to the hospital.
"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, which was assisting with the transfers.
She said that, "It was a mistake and I heard from the family on Saturday that they were very concerned."
Doyle said that the man's 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."
Once Doyle learned of their concern, she called the Rosslyn home. Doyle was put in touch with security there and they then discovered the man in his room.
The man was "alert" upon his discovery, according to Doyle, who not provide further details to protect the man's privacy. He has since been transferred to the COVID-19 unit at St. Joe's Charlton Campus and remains in stable condition.
In the time that passed while the man was forgotten, Doyle assured the press that he had access to a washroom although could not verify whether or not he had access to his medication.
"We did respond back there for a patient on Saturday," said Hamilton paramedic superintendent Dave Thompson, who said he was not fully aware of the nature of the call.
The 52 Rosslyn residents were transferred to two different hospitals, the bulk of which went to St. Joe's.
"The home wasn't meeting the safety standards that needed to be met," said Doyle, who referred to the outbreak as "a very serious concern" given the number of residents infected.
It took approximately eight hours to transfer everybody from the home to St. Joe's and the transfer was a "co-ordinated effort" between Hamilton EMS, police, hospitals and the Rosslyn home.
Doyle believes the man was missed because the regular staff at Rosslyn Residence have already been diagnosed with the virus and weren't at work because they were in self-isolation. "There wasn't one regular member of the staff working in the home," said Doyle.
On top of that the residence did not have a master list of the Rosslyn residents that was up-to-date, leaving the paramedics and staff assisting with the transfer without the proper information. The staff tried to assemble the resident's records themselves, however there was another problem which was that the home told them that the man had already been transferred to a the hospital the week before when the outbreak was initially declared on May 10.
Public health officials reported that as of Tuesday, the home had 63 resident cases at the 64-unit home. An additional 20 members of the staff had also already tested positive and two residents had died.
"We had been told by the home that the individual had been transferred to the hospital earlier in the week," said Doyle.
"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," said continued.
The hospital continues to investigate how the error occurred.
"It's a situation everybody would want to avoid," said Doyle. "We've absolutely had some learning from this."
Doyle said ultimately the responsibility lies with the owner and operator of the Rosslyn Residence, saying, "once you get into this sort of a crisis situation... we need to be very clear so everybody fully understands their accountability and responsibility."