Sydney aged care home Newmarch House received conflicting opinions about the wearing of personal protective equipment during the early stages of its deadly coronavirus outbreak, a royal commission has heard.
The facility's pandemic response was also hampered by "dysfunctional" discussions involving state and federal governments, and by a struggle to obtain protective gear for staff.
Seventeen Newmarch residents died from COVID-19 after the first positive case on April 11.
Grant Millard, CEO of Anglicare Sydney which runs Newmarch House, said there were "heated discussions" with state and federal authorities about whether virus-positive residents should be hospitalised.
Of 37 positive residents, two were transferred to hospital. One of those died, with the other 16 fatalities occurring at the home.
The facility adopted a 'hospital in the home' approach.
However, Mr Millard told the commission that in hindsight he would have pushed harder for the transfer of infected residents to hospital.
He said it would have lessened the likelihood of staff contracting the virus and allowed residents to move more freely.
"It was extremely difficult for residents to be isolated in their rooms with the doors closed," he said on Tuesday.
Notes from an Anglicare board meeting on May 6 describe a "frustrating level of dysfunction" in discussions between Newmarch House, government departments and employees.
Mr Millard said it was "particularly intense" over the first fortnight of the outbreak, which was ultimately declared over in mid-June.
"Everyone was clearly ... passionate about how this could be dealt with quickly and for the expert opinion to be declared," he said.
"But it just wasn't clear who was in a position to give that advice."
The home struggled to source PPE and received different advice about when to use it, the commission heard.
Mr Millard said infectious disease expert James Branley advised staff to wear full PPE around all residents, but NSW Health said it was only to be used when treating positive and suspected cases.
"It was deeply distressing," Mr Millard said, adding it felt like the home had to "plead" for required resources early on.
Mr Millard said PPE shortages meant more staff had to be taken off the job and put in precautionary quarantine.
In all, 37 staff tested positive and the home lost 87 per cent of its workforce within days of the outbreak starting.
"We were scratching around (for staff) and people were scared," Mr Millard said.
"They were terrified of COVID and it was difficult to get people."
In a regulator-required self-assessment conducted the month before its first case, Newmarch House rated itself well-prepared to handle a pandemic.
Virginia Clarke told the aged care commission that communication from the facility about her father Ron Farrell was poor.
She didn't find out about his positive test result until a manager called her on a routine check-up. Mr Farrell, 94, later died of the virus.
"She said 'you don't know?'. And I said 'no'. She said 'I'm really really sorry, he got his results back and he tested positive for COVID-19'."
"I was in shock. I didn't know what to say."
Mr Millard conceded the home was "absolutely overwhelmed" with the challenges of dealing with the virus and regretted not properly communicating with residents' families.
"It has been traumatic for everyone involved in this situation," he said.
The aged care royal commission is holding hearings over three days to examine the sector's virus response, but the situation in Victoria is not part of the scope due to its evolving nature.
Australian Associated Press