The Herron nursing home in Dorval, Que., was understaffed and disorganized long before the pandemic struck, the former director of care told a coroner's inquiry on Monday.
Véronique Bossé began working at the privately run long-term care home in September 2019 and left in January 2020.
Her mother, Viviane Blanchard, was also a resident at the home. Blanchard died on April 7, 2020, at the height of the crisis at Herron.
In her testimony Monday, Bossé said patient files weren't up to date, and there were chronic staff shortages at the home.
"There weren't enough workers," she told Coroner Géhane Kamel, who is presiding over the inquest into Herron.
This, she said, was as a result of low wages. Bossé said patient attendants at the residence were earning $12 an hour when she started there in 2019.
"It was underpaid for the tasks they had to do,'' she said, adding that whenever she would bring concerns about staff shortages to the administration, she would be told it was a question of money.
Bossé questioned the push for profits in private residences such as Herron. "Why does it have to be profitable to the detriment of the quality and the care we give to the elderly?'' she asked.
She said equipment and supplies were also lacking. There were, for instance, five washcloths available to bathe 15 patients, and such a shortage of adult diapers that staff would stash them to ensure they had enough, she said.
Bossé said she tried to change things for the better but grew frustrated and returned to a job in the public system.
Her mother, who had Alzheimer's but was otherwise in good health, remained at Herron as a patient.
The inquiry, which began last week, has heard from staff and health officials about the poor co-ordination between health officials and the owners of Herron, the Katasa Group, that resulted in residents lacking basic care for more than a week in late March and early April of that year.
Staff at the West Island health authority, the CIUSSS de l'Ouest-de-l'Île-de-Montréal, were aware of the appalling conditions after visiting the home on March 29, the inquiry has heard.
But the acute staffing shortage remained in place for several days and the health authority only formally took over on April 9. By that point, 31 people had died.
During her testimony, Bossé recounted how she would telephone Herron during her mother's final days to find out how she was faring. She said she often was sent to voicemail, where she heard her own voice.
The message hadn't been changed since she had left her post.
Bosse's mother died on April 7.
"In my mind, she died of thirst, of hunger. Also, her oxygen tank was empty,'' she said. "She ran out of oxygen.''
The coroner's mandate is to investigate 53 deaths at six long-term care homes and one seniors' residence.