Carlingview Manor cited for security issues before woman's fatal fall

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Just months before an elderly woman apparently fell to her death outside Carlingview Manor in April, the long-term care home was ordered to fix a problem with the security of its exits.

The home had been found earlier this year to be non-compliant with provincial regulations concerning the security of outside doors and alarm systems.

On April 17, a female resident, whose name has not been released, was found near a wall outside of the seven-storey long-term care home on Carling Avenue. Paramedics said she had suffered significant trauma “consistent with a fall from a great height.” She was in cardiac arrest when paramedics arrived and died at the scene, according to Ottawa paramedic spokesperson Marc-Antoine Deschamps. No other details about the incident have been made public.

Police are investigating the death, as is the Ministry of Health and Long-Term Care.

Prior to the incident, the long-term care home at 2330 Carling Avenue, had issues with the security of its exit doors and with security devices worn by residences who might attempt to leave the building.

Wendy Gilmour, senior vice-president for long-term care for Revera Inc., which runs the home, said in a statement Monday that all doors were “operating as expected and in compliance with ministry requirements” at the time of the incident. Staff at the long-term care home are continuing to work with investigators from the Ministry of Health and Long-Term Care, he added.

“We are not able to provide any further details until the ongoing investigation is complete.”

In January, the province found the home had failed to comply with provincial rules that all outside doors — including doors leading to balconies or terraces — be locked, equipped with a working alarm system and regularly tested. It ordered the home to fix the problem by March 15 and do manual checks of all exit doors three times a day until then to make sure they were locked.

A year earlier, in January 2017, a resident left Carlingview Manor without being detected and was missing for several hours before being located by police. That resident, who suffers from dementia, had to be treated for unspecified injuries suffered during that time.

Inspectors later found that an exit door on the building’s main floor was not locking and that the problem had been reported weeks earlier. There was no documentation available to show whether action was taken to ensure security of residents after the problem was found, according to the inspection report.

Staff also told inspectors they did not recall an alarm connected to the resident’s signalling device going off while they searched. The signalling devices are designed to make a sound when a resident wearing one is near an exit door. Those devices are to be checked daily. Provincial inspectors found several dates in which there were no records of the device having been checked.

Security of long-term care residents is a complex issue, given the high number of residents who have some form of dementia, including those who try to leave the homes. Door security, alarm systems, frequent testing and monitoring are all part of security systems for long-term care homes. Carlingview Manor, according to the inspection report, conducts weekly tests of its exit doors and daily checks that patients’ signalling systems are working.

The provincial government has announced it will implement financial penalties for long-term care operators who are chronically not in compliance with provincial laws. Every home in Ontario undergoes a comprehensive quality inspection each year. Inspections and investigations also take place when incidents occur.

A spokesman for the Ministry of Health and Long-Term Care said it began an inspection as soon as it was notified of the death in April. When the inspection is complete, a report will be posted on the ministry’s website.

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