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Pauline D’Amour sat in stunned silence as she learned for the first time the details of her father’s death.
Marcel D’Amour died two years ago at age 82 while in care at Residence Saint-Louis, his body found lying face down next to his wheelchair outside on the property — a 198-bed long-term care facility on Hiawatha Park Road in Orléans.
Since 2012, at least 17 people have died in Ottawa long-term care homes. In each case, the care residents received before their deaths led to citations for failing to comply with provincial legislation, an investigation by this newspaper found.
Through a substantive review of ministry inspection reports, this newspaper also uncovered 163 reported abuse cases and 2,033 instances of non-compliance with provincial regulations.
The death of D’Amour accounted for numerous citations against Residence Saint-Louis, the worst-offending home for non-compliance since 2012. But that’s something his family never learned, until now.
“We never got any results from the investigations,” said Pauline D’Amour. “The nurse told me they do an investigation and she told me to look for (the results) on the internet. I never saw anything.”
The Gatineau woman had asked for the results of an investigation into D’Amour’s death on Sept. 5, 2015, and she said administrators told the grieving daughter to look it up on the Ministry of Health and Long-Term Care website.
She could barely contain her anger two years later when told by a reporter the results of that investigation.
“What? Oh my God, come on,” she exclaimed when told staff had waited hours before calling police after Marcel D’Amour was reported missing from his room that day. She recalled getting the voice mail from the home that evening, and contacting a nurse around 7 p.m., urging staff to “do what was necessary” to find him.
By that time, nursing staff hadn’t seen her father since his noon medications. He wasn’t in his room when they went to deliver his next round at 4 p.m.
He was still missing for 5 p.m. suppertime, which, as a diabetic, he never missed.
“When the nurse called me, and I found that out that my father wasn’t there for supper, I said, ‘Are you looking for him?’” said D’Amour.
According to a timeline established in a ministry report, nursing staff did not comply with established Code Yellow procedures for a missing patient.
According to the report into Marcel D’Amour’s death (though the public report does not identify the resident by name or gender), staff left voice messages with the man’s next of kin around 5:30 p.m. and made contact at 7 p.m. that evening.
Pauline D’Amour recalls answering “no” when a nurse asked whether the missing man was with family. She implored the nurse to find her father.
Despite the family’s pleas, a nurse told staff “to not contact the police department for now,” as D’Amour had been known to leave the grounds without notifying nursing staff, according to the report.
When Pauline D’Amour learned those details of the ministry inspection into her father’s death, she paused in silence before saying only, “Appalling.”
Instead, staff asked a security guard to search the property around 8 p.m., a search the unnamed guard conducted in his personal car, “getting out of the vehicle occasionally and shining his high-beam into the darkness.”
Still missing at 9:30 p.m., more than nine hours after staff had last seen Marcel D’Amour, the residence notified police.
Two officers arrived at 10:20 p.m. and interviewed staff and took over the search. It would be another hour before five officers started searching the building.
“By the time I got a call back from the head nurse it was 10 o’clock and they still hadn’t found him,” said Pauline D’Amour. “So I said, ‘What are you waiting for to get the police involved?’
“They took their sweet time, because I was (next) called after midnight, and it was the police by then, saying they hadn’t found him and they were still searching for him.
“You do stupid things when you’re in that situation. Even though I didn’t have my licence I should’ve went and drove there,” she said, her voice cracking with emotion.
Police found Marcel D’Amour at 1 a.m., lying dead outside, face down near his wheelchair, still on the property.
Pauline said her brother Michel was awakened early that morning by police knocking on the door to announce their father had been found.
“From what I could hear, he was still on the property,” Pauline D’Amour said. “They said they would do an investigation, but I never saw the results of it. They didn’t let us know anything.”
Worse for the family, said D’Amour, no one would allow them to see the body.
“I asked to see him and they said he fell face down and all the blood rushed to his head, so he wasn’t really recognizable. So to me, it’s like there’s no closure, you know? We had that right to see him. But the coroner said no and the funeral home said no, so to me there’s no closure.”
Friendly and independent, Marcel D’Amour was known by Residence Saint-Louis staff to move freely around the property aided by his electric wheelchair. Senior nursing staff later told ministry inspectors they knew the resident was “mentally capable, propelling an electric wheelchair and needed treatment for a wound, and taking medications for (his) medical conditions.”
Marcel D’Amour, the report noted, “was known to have regular habits to go outside unaccompanied … without recording his outings” and “rarely informed staff” of his whereabouts.
“He was a friendly guy. He got along with everybody,” said Pauline D’Amour. “And since my mom passed away of Alzheimer’s at the same place, he would mingle with some elderly chaps, play cards on Friday afternoons. This was a Friday.”
D’Amour said she fought to have her elderly parents reunited in Residence Saint-Louis several years ago, after her mother Lorraine was referred to the home, and placed in the first-floor ward with others suffering from Alzheimer’s and dementia.
“So I had Mom crying on one side and Dad (at a different residence) crying on the other, so I made some calls and got them to put them together.
“Mom really depended on Dad,” Pauline D’Amour said. “And it was tough when they were apart. They were married 56 years. It was hard on both of them. They were apart for about three months, and it just wasn’t feasible to see them apart.”
Marcel D’Amour moved into a room on the fourth floor. He was devastated after Lorraine died, Pauline D’Amour said. He made friends at the home, and would regularly help out with other residents.
“My father had his little routine. He had his scooter and he had his little trail where he would go to the Metro, and get his ginger ale, pick up his vitamins and medication at the pharmacy. He would usually come back for suppertime. He never missed it. And because he was diabetic, he never missed checking his blood sugar or his insulin.”
The city was in the midst of a humid heat wave that early September day, Pauline D’Amour recalled.
“He fell face down and had a massive heart attack. The police talked to the people in the store, and some people said they saw him, but we’ll never know the whole story behind that.”
As upset as she was to learn the results of the ministry inspection, Pauline D’Amour was equally angered upon learning of Residence Saint-Louis’s response to an official government reprimand over the matter.
An inspector ordered the residence to fix gaps in its Code Yellow policies, among other measures, in a Nov. 17, 2015 decision related to the death of the missing resident, according to public ministry reports.
The same order was issued after an inspection four months later with the home still not in compliance.
In yet another followup inspection in October 2016, a year after D’Amour’s death, an investigator found some staff had still not been properly educated on the revised policies.
The administrator “did not provide the education to any of their support staffs including dietary, housekeeping, maintenance and activity … the revised Code Yellow policy was not provided to all employees in the home, including managers. Not all residents who had been identified as being able to leave the home on their own had their written plan of care.”
The Ministry inspector concluded the “scope and severity of the compliance order … (and) the fact that employees may still not have the knowledge required to effectively respond and address the safety needs of residents who may not return from an unaccompanied leave poses a risk to those residents.”
Melissa Donskov, executive director of long-term care with Bruyère Continuing Care, took over duties as top administrator at Residence Saint-Louis earlier this year.
Donskov confirmed the residence has since complied with the ministry order involving Code Yellow procedures for missing patients, with the new administration making ministry compliance a “top priority.”
“We do recognize there are areas that have needed to be addressed, and we’ve committed to doing it,” she said. “We’ve done extensive work to achieve compliance, from policies and education to putting processes in place, working with our residents and families. We’re really on the right path, with a robust system to ensure compliance, and we are seeing improvement.”
That was welcome news, but small comfort to Pauline D’Amour.
“That’s all fine,” she said. “But it doesn’t bring my father back.”
With files from Drake Fenton
ahelmer@postmedia.com
Twitter.com/helmera
查看原文...
Marcel D’Amour died two years ago at age 82 while in care at Residence Saint-Louis, his body found lying face down next to his wheelchair outside on the property — a 198-bed long-term care facility on Hiawatha Park Road in Orléans.
Since 2012, at least 17 people have died in Ottawa long-term care homes. In each case, the care residents received before their deaths led to citations for failing to comply with provincial legislation, an investigation by this newspaper found.
Through a substantive review of ministry inspection reports, this newspaper also uncovered 163 reported abuse cases and 2,033 instances of non-compliance with provincial regulations.
The death of D’Amour accounted for numerous citations against Residence Saint-Louis, the worst-offending home for non-compliance since 2012. But that’s something his family never learned, until now.
“We never got any results from the investigations,” said Pauline D’Amour. “The nurse told me they do an investigation and she told me to look for (the results) on the internet. I never saw anything.”
The Gatineau woman had asked for the results of an investigation into D’Amour’s death on Sept. 5, 2015, and she said administrators told the grieving daughter to look it up on the Ministry of Health and Long-Term Care website.
She could barely contain her anger two years later when told by a reporter the results of that investigation.
“What? Oh my God, come on,” she exclaimed when told staff had waited hours before calling police after Marcel D’Amour was reported missing from his room that day. She recalled getting the voice mail from the home that evening, and contacting a nurse around 7 p.m., urging staff to “do what was necessary” to find him.
By that time, nursing staff hadn’t seen her father since his noon medications. He wasn’t in his room when they went to deliver his next round at 4 p.m.
He was still missing for 5 p.m. suppertime, which, as a diabetic, he never missed.
“When the nurse called me, and I found that out that my father wasn’t there for supper, I said, ‘Are you looking for him?’” said D’Amour.
According to a timeline established in a ministry report, nursing staff did not comply with established Code Yellow procedures for a missing patient.
According to the report into Marcel D’Amour’s death (though the public report does not identify the resident by name or gender), staff left voice messages with the man’s next of kin around 5:30 p.m. and made contact at 7 p.m. that evening.
Pauline D’Amour recalls answering “no” when a nurse asked whether the missing man was with family. She implored the nurse to find her father.
Despite the family’s pleas, a nurse told staff “to not contact the police department for now,” as D’Amour had been known to leave the grounds without notifying nursing staff, according to the report.
When Pauline D’Amour learned those details of the ministry inspection into her father’s death, she paused in silence before saying only, “Appalling.”
Instead, staff asked a security guard to search the property around 8 p.m., a search the unnamed guard conducted in his personal car, “getting out of the vehicle occasionally and shining his high-beam into the darkness.”
Still missing at 9:30 p.m., more than nine hours after staff had last seen Marcel D’Amour, the residence notified police.
Two officers arrived at 10:20 p.m. and interviewed staff and took over the search. It would be another hour before five officers started searching the building.
“By the time I got a call back from the head nurse it was 10 o’clock and they still hadn’t found him,” said Pauline D’Amour. “So I said, ‘What are you waiting for to get the police involved?’
“They took their sweet time, because I was (next) called after midnight, and it was the police by then, saying they hadn’t found him and they were still searching for him.
“You do stupid things when you’re in that situation. Even though I didn’t have my licence I should’ve went and drove there,” she said, her voice cracking with emotion.
Police found Marcel D’Amour at 1 a.m., lying dead outside, face down near his wheelchair, still on the property.
Pauline said her brother Michel was awakened early that morning by police knocking on the door to announce their father had been found.
“From what I could hear, he was still on the property,” Pauline D’Amour said. “They said they would do an investigation, but I never saw the results of it. They didn’t let us know anything.”
Worse for the family, said D’Amour, no one would allow them to see the body.
“I asked to see him and they said he fell face down and all the blood rushed to his head, so he wasn’t really recognizable. So to me, it’s like there’s no closure, you know? We had that right to see him. But the coroner said no and the funeral home said no, so to me there’s no closure.”
Friendly and independent, Marcel D’Amour was known by Residence Saint-Louis staff to move freely around the property aided by his electric wheelchair. Senior nursing staff later told ministry inspectors they knew the resident was “mentally capable, propelling an electric wheelchair and needed treatment for a wound, and taking medications for (his) medical conditions.”
Marcel D’Amour, the report noted, “was known to have regular habits to go outside unaccompanied … without recording his outings” and “rarely informed staff” of his whereabouts.
“He was a friendly guy. He got along with everybody,” said Pauline D’Amour. “And since my mom passed away of Alzheimer’s at the same place, he would mingle with some elderly chaps, play cards on Friday afternoons. This was a Friday.”
D’Amour said she fought to have her elderly parents reunited in Residence Saint-Louis several years ago, after her mother Lorraine was referred to the home, and placed in the first-floor ward with others suffering from Alzheimer’s and dementia.
“So I had Mom crying on one side and Dad (at a different residence) crying on the other, so I made some calls and got them to put them together.
“Mom really depended on Dad,” Pauline D’Amour said. “And it was tough when they were apart. They were married 56 years. It was hard on both of them. They were apart for about three months, and it just wasn’t feasible to see them apart.”
Marcel D’Amour moved into a room on the fourth floor. He was devastated after Lorraine died, Pauline D’Amour said. He made friends at the home, and would regularly help out with other residents.
“My father had his little routine. He had his scooter and he had his little trail where he would go to the Metro, and get his ginger ale, pick up his vitamins and medication at the pharmacy. He would usually come back for suppertime. He never missed it. And because he was diabetic, he never missed checking his blood sugar or his insulin.”
The city was in the midst of a humid heat wave that early September day, Pauline D’Amour recalled.
“He fell face down and had a massive heart attack. The police talked to the people in the store, and some people said they saw him, but we’ll never know the whole story behind that.”
As upset as she was to learn the results of the ministry inspection, Pauline D’Amour was equally angered upon learning of Residence Saint-Louis’s response to an official government reprimand over the matter.
An inspector ordered the residence to fix gaps in its Code Yellow policies, among other measures, in a Nov. 17, 2015 decision related to the death of the missing resident, according to public ministry reports.
The same order was issued after an inspection four months later with the home still not in compliance.
In yet another followup inspection in October 2016, a year after D’Amour’s death, an investigator found some staff had still not been properly educated on the revised policies.
The administrator “did not provide the education to any of their support staffs including dietary, housekeeping, maintenance and activity … the revised Code Yellow policy was not provided to all employees in the home, including managers. Not all residents who had been identified as being able to leave the home on their own had their written plan of care.”
The Ministry inspector concluded the “scope and severity of the compliance order … (and) the fact that employees may still not have the knowledge required to effectively respond and address the safety needs of residents who may not return from an unaccompanied leave poses a risk to those residents.”
Melissa Donskov, executive director of long-term care with Bruyère Continuing Care, took over duties as top administrator at Residence Saint-Louis earlier this year.
Donskov confirmed the residence has since complied with the ministry order involving Code Yellow procedures for missing patients, with the new administration making ministry compliance a “top priority.”
“We do recognize there are areas that have needed to be addressed, and we’ve committed to doing it,” she said. “We’ve done extensive work to achieve compliance, from policies and education to putting processes in place, working with our residents and families. We’re really on the right path, with a robust system to ensure compliance, and we are seeing improvement.”
That was welcome news, but small comfort to Pauline D’Amour.
“That’s all fine,” she said. “But it doesn’t bring my father back.”
With files from Drake Fenton
ahelmer@postmedia.com
Twitter.com/helmera
查看原文...
