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Multiple Ottawa long-term care homes have seen fresh cases of abuse and resident death following improper care, an analysis of provincial records published this year reveals.
One resident died after being pushed to the ground by another resident, while it’s alleged a resident in a different home was repeatedly sexually abused by another resident.
Both cases led to citations against the homes by the Ministry of Health and Long-Term Care.
City-run nursing homes, which have been under scrutiny following previous incidents of abuse, have been the site of nearly half the cases of abuse documented in reports in 2018.
Last year, this newspaper did a substantive audit of ministry records for Ottawa care homes between 2012 to 2017, chronicling cases of abuse, death and non-compliance with legislation governing long-term care in Ontario.
This newspaper has now conducted a similar review of reports published in the first few months of this calendar year. The results underscore the challenges being faced by nursing homes, by residents and their families, and by staff across the city.
Of the 27 long-term care homes in Ottawa, 16 have so far been the subject of ministry inspection reports.
This newspaper’s review shows there have been 83 incidents of non-compliance, 16 reported abuse cases and four cases where the care a resident received before death led to a ministry citation.
Homes can be found non-compliant with ministry legislation for a number of reasons, ranging from a severe instance of staff-to-resident abuse to something more moderate, such as poor record keeping.
Seven of the 16 abuse cases documented in reports published this year occurred in city-run homes.
Just last week, the city said it had satisfied the requirements of a provincial order issued last summer over the state of its four long-term care homes.
The Health Ministry issued the order after seeing evidence of non-compliance when it came to protecting residents from abuse and neglect. Those types of incidents have been documented in this newspaper, including one case in which an elderly man with dementia was punched in the face by a personal support worker.
While there have been multiple new cases of reported abuse in city-run homes, the city says those cases occurred before recent “training and other strategies were implemented” to prevent abuse.
There is often a lag time between the publication of ministry reports and the incidents they cover. The reports reviewed by this newspaper were all published in 2018; however, some of the incidents happened in the final months of 2017, while others happened in the first few months of this year.
One such incident was at Villa Marconi, off Baseline Road. A ministry report published on Jan. 29, 2018 details events that led to the death of a resident on an unspecified date in 2017.
The home was found non-compliant with ministry legislation after a resident with a history of physical aggression pushed another resident “without provocation” to the floor.
The injured resident died in hospital four days later as a result of the fall.
The behaviour of both residents was not properly documented by staff at the home, the ministry found. The resident with a history of violence had eight instances of physical aggression toward one resident and several staff members, the report said.
The resident’s moods and behaviours were documented inconsistently, and no interventions were developed for monitoring the resident.
Likewise, no plan was in place for monitoring the resident who died. That resident was seen frequently wandering around the home and sometimes “exhibiting agitated behaviours.” Interventions were not implemented to minimize the risk of an altercation between the two residents, the report said.
The ministry found the home failed to report the incident immediately to the home’s director, and failed to implement procedures to assist residents and staff who were at risk of harm or harming.
Villa Marconi did not respond to comment requests from this newspaper.
Near the city’s downtown core, a resident at Résidence Élisabeth-Bruyère was the subject of multiple non-compliance citations, all related to reported resident-on-resident sexual abuse.
Due to privacy concerns, ministry reports do not name residents. Instead, reports designate residents numerically. In this case, the report focused on “resident #012,” a dementia patient who had “eleven incidents where behaviours of a sexual nature were exhibited toward resident #008, #049 and staffs within a nine month period,” according to a Feb. 23, 2018 report.
The extent of the reported abuse was left vague in the report. Resident 012 is said to have had “inappropriate behaviours of sexual nature toward resident #049.” Resident 049 was unable to provide consent, the report said.
Resident 008 denied resident 012’s advances and was met with “inappropriate verbal comments,” the report also said.
While the home took some action to prevent resident 012’s behaviour, an inspector found the home failed to do enough to protect other residents and staff.
“Resident #012 exhibited nine incidents of a sexual nature to resident #049 in a period of five months and even after being moved to a different floor the resident continued to exhibit incidents of a sexual nature toward an identified resident and toward staff, posing a great risk of harm to those people,” the report said.
The home was ordered by the province to establish a process “to ensure that actions are taken to respond to resident #012’s responsive behaviours.”
Resident 049’s experience with reported sexual abuse didn’t end with resident 012. Resident 049 was also allegedly sexually abused by another resident, the same report said, though the nature of the reported abuse was not detailed.
The home was slapped with a non-compliance order after a failure to report the alleged abuse properly.
When reached for comment, a spokesperson for Bruyère said the home takes the province’s orders around compliance “very seriously” and is working “diligently” to address key areas of concern.
“Any time there is an area identified by the ministry around compliance, we see this as an opportunity to make improvements. We are a teaching organization and we will do what it takes to ensure that we meet all the standards. This is a work in progress and addressing any areas of compliance is a top priority for Bruyère’s long-term care homes,” the home said.
At the four city-run homes — Centre d’accueil Champlain, Peter D. Clark, Garry J. Armstrong and Carleton Lodge — the cases of reported abuse involved both resident-on-resident and staff-on-resident abuse.
At Centre d’accueil Champlain, a Feb. 2, 2018 report found the home had failed to comply with its own zero-tolerance abuse policy after one resident allegedly sexually abused another resident who was cognitively impaired.
On an unspecified date, staff members spotted a resident in another resident’s room, removing that resident’s top. The alleged victim’s continence product had been half ripped off, said the report, while the victim struggled to hold on to their top as it was unfastened.
Workers rushed to call for help and remove the alleged offender. One registered nurse who responded decided to send an email to her manager at the end of her shift, which was eventually read three hours later. The report determined the nurse failed to take immediate action to contact the manager on-call, as per the home’s policy.
In another case of alleged resident-on-resident sexual abuse, this time at the Peter D. Clark centre in Nepean, a Feb. 5, 2018 report found the home was non-compliant for failing to follow its abuse policy.
Three staff members had to separate two residents with dementia after an incident of alleged sexual abuse. A nurse told the pair they could not have “interactions of a sexual nature” and that one of them would be moved to the other side of the unit.
Afterward, there was confusion between staff over whether an “assessment of capacity” should be or had been applied with either resident, even after a nurse indicated one of the residents was not “capable.” The report ultimately found the home was in violation for not carrying out an assessment. The home was also found non-compliant after staff hesitated a day to report the alleged abuse to the director, because they were unsure about the nature of the incident.
Peter D. Clark was also cited for a case in which a personal support worker allegedly emotionally and physically abused a resident. (In an interview with the inspector, a registered nurse acknowledged the incident, but said the resident had been known to fabricate in the past.)
The alleged abuse was reported three days later, violating the home’s policy to report abuse cases immediately.
At Garry J. Armstrong, a Jan. 31, 2018 report said the home failed to ensure its policies were properly carried out after a resident fell and died on the same day.
After the resident failed to show up for lunch, a personal support worker found the resident fallen on the floor, according to the report. One nurse interviewed said whenever a fall is unwitnessed — as it was in this case — a head injury inspection should be done.
The report is unclear as to whether or not the resident died from the fall. Ultimately, however, the report determined certain protocols regarding a medical evaluation of the resident were not documented and completed correctly, and the resident’s motor response or pupils were never assessed before their death.
In a Feb. 9, 2018 report, a personal support worker witnessed a resident touching another resident inappropriately on an unspecified date in 2017 at Carleton Lodge.
The worker told a ministry inspector that she “believed that the incident was sexual abuse, however, she did not report the incident immediately” because she had “gotten busy with other residents and forgot to report the incident.”
The worker was then off for two days and said she remembered the incident and reported it once she returned to work.
By neglecting to report the reported case of abuse immediately, the ministry found the home had failed to ensure that its own abuse policy was followed.
“The City of Ottawa stands firm on its commitment to continuous improvement in the delivery of care for our residents and to ensure a healthy and safe environment,” said Janice Burelle, the city’s community and social services general manager, in an emailed statement. “Part of that commitment includes the actions implemented between October 2017 and January 2018 as outlined in the five work plans provided to the province in the fall of 2017.”
Those actions include items such as enhanced staff training on the prevention of abuse and neglect and an “additional management presence” on evenings and weekends that includes checklists and followups.
There are also new tools to help staff assist residents from “diverse cultural backgrounds.”
As well, an independent third-party reviewer is conducting an assessment of the city’s four homes to provide recommendations aimed at preventing incidents of abuse. The report will be completed by the end of April 2018.
“Concrete actions will be developed and implemented stemming from these recommendations,” Burelle said.
When reached for comment, the Health Ministry said it “is continuing to meet with the City of Ottawa on a monthly basis” and is receiving “progress reports to maintain close monitoring of actions being taken locally.”
The ministry also said the ability to levy financial penalties against homes repeatedly found non-compliant with provincial rules is closer to fruition — a long-sought request from long-term care advocates. The ability to fine homes was introduced in legislation last December, but is currently not available as the government awaits public feedback on draft regulations.
Following input from the public, which can be done until the end of March, the ministry will “communicate with the long-term care sector about the new penalties and how they will be used to strengthen enforcement and achieve compliance with operators where recurring issues exist.”
Do you know more about the incidents detailed in this story? Contact our reporters.
amah@postmedia.com
Twitter.com/alisonmah
dfenton@postmedia.com
Twitter.com/drakefenton
查看原文...
One resident died after being pushed to the ground by another resident, while it’s alleged a resident in a different home was repeatedly sexually abused by another resident.
Both cases led to citations against the homes by the Ministry of Health and Long-Term Care.
City-run nursing homes, which have been under scrutiny following previous incidents of abuse, have been the site of nearly half the cases of abuse documented in reports in 2018.
Last year, this newspaper did a substantive audit of ministry records for Ottawa care homes between 2012 to 2017, chronicling cases of abuse, death and non-compliance with legislation governing long-term care in Ontario.
This newspaper has now conducted a similar review of reports published in the first few months of this calendar year. The results underscore the challenges being faced by nursing homes, by residents and their families, and by staff across the city.
Of the 27 long-term care homes in Ottawa, 16 have so far been the subject of ministry inspection reports.
This newspaper’s review shows there have been 83 incidents of non-compliance, 16 reported abuse cases and four cases where the care a resident received before death led to a ministry citation.
Homes can be found non-compliant with ministry legislation for a number of reasons, ranging from a severe instance of staff-to-resident abuse to something more moderate, such as poor record keeping.
Seven of the 16 abuse cases documented in reports published this year occurred in city-run homes.
Just last week, the city said it had satisfied the requirements of a provincial order issued last summer over the state of its four long-term care homes.
The Health Ministry issued the order after seeing evidence of non-compliance when it came to protecting residents from abuse and neglect. Those types of incidents have been documented in this newspaper, including one case in which an elderly man with dementia was punched in the face by a personal support worker.
While there have been multiple new cases of reported abuse in city-run homes, the city says those cases occurred before recent “training and other strategies were implemented” to prevent abuse.
There is often a lag time between the publication of ministry reports and the incidents they cover. The reports reviewed by this newspaper were all published in 2018; however, some of the incidents happened in the final months of 2017, while others happened in the first few months of this year.
One such incident was at Villa Marconi, off Baseline Road. A ministry report published on Jan. 29, 2018 details events that led to the death of a resident on an unspecified date in 2017.
The home was found non-compliant with ministry legislation after a resident with a history of physical aggression pushed another resident “without provocation” to the floor.
The injured resident died in hospital four days later as a result of the fall.
The behaviour of both residents was not properly documented by staff at the home, the ministry found. The resident with a history of violence had eight instances of physical aggression toward one resident and several staff members, the report said.
The resident’s moods and behaviours were documented inconsistently, and no interventions were developed for monitoring the resident.
Likewise, no plan was in place for monitoring the resident who died. That resident was seen frequently wandering around the home and sometimes “exhibiting agitated behaviours.” Interventions were not implemented to minimize the risk of an altercation between the two residents, the report said.
The ministry found the home failed to report the incident immediately to the home’s director, and failed to implement procedures to assist residents and staff who were at risk of harm or harming.
Villa Marconi did not respond to comment requests from this newspaper.
Near the city’s downtown core, a resident at Résidence Élisabeth-Bruyère was the subject of multiple non-compliance citations, all related to reported resident-on-resident sexual abuse.
Due to privacy concerns, ministry reports do not name residents. Instead, reports designate residents numerically. In this case, the report focused on “resident #012,” a dementia patient who had “eleven incidents where behaviours of a sexual nature were exhibited toward resident #008, #049 and staffs within a nine month period,” according to a Feb. 23, 2018 report.
The extent of the reported abuse was left vague in the report. Resident 012 is said to have had “inappropriate behaviours of sexual nature toward resident #049.” Resident 049 was unable to provide consent, the report said.
Resident 008 denied resident 012’s advances and was met with “inappropriate verbal comments,” the report also said.
While the home took some action to prevent resident 012’s behaviour, an inspector found the home failed to do enough to protect other residents and staff.
“Resident #012 exhibited nine incidents of a sexual nature to resident #049 in a period of five months and even after being moved to a different floor the resident continued to exhibit incidents of a sexual nature toward an identified resident and toward staff, posing a great risk of harm to those people,” the report said.
The home was ordered by the province to establish a process “to ensure that actions are taken to respond to resident #012’s responsive behaviours.”
Resident 049’s experience with reported sexual abuse didn’t end with resident 012. Resident 049 was also allegedly sexually abused by another resident, the same report said, though the nature of the reported abuse was not detailed.
The home was slapped with a non-compliance order after a failure to report the alleged abuse properly.
When reached for comment, a spokesperson for Bruyère said the home takes the province’s orders around compliance “very seriously” and is working “diligently” to address key areas of concern.
“Any time there is an area identified by the ministry around compliance, we see this as an opportunity to make improvements. We are a teaching organization and we will do what it takes to ensure that we meet all the standards. This is a work in progress and addressing any areas of compliance is a top priority for Bruyère’s long-term care homes,” the home said.
At the four city-run homes — Centre d’accueil Champlain, Peter D. Clark, Garry J. Armstrong and Carleton Lodge — the cases of reported abuse involved both resident-on-resident and staff-on-resident abuse.
At Centre d’accueil Champlain, a Feb. 2, 2018 report found the home had failed to comply with its own zero-tolerance abuse policy after one resident allegedly sexually abused another resident who was cognitively impaired.
On an unspecified date, staff members spotted a resident in another resident’s room, removing that resident’s top. The alleged victim’s continence product had been half ripped off, said the report, while the victim struggled to hold on to their top as it was unfastened.
Workers rushed to call for help and remove the alleged offender. One registered nurse who responded decided to send an email to her manager at the end of her shift, which was eventually read three hours later. The report determined the nurse failed to take immediate action to contact the manager on-call, as per the home’s policy.
In another case of alleged resident-on-resident sexual abuse, this time at the Peter D. Clark centre in Nepean, a Feb. 5, 2018 report found the home was non-compliant for failing to follow its abuse policy.
Three staff members had to separate two residents with dementia after an incident of alleged sexual abuse. A nurse told the pair they could not have “interactions of a sexual nature” and that one of them would be moved to the other side of the unit.
Afterward, there was confusion between staff over whether an “assessment of capacity” should be or had been applied with either resident, even after a nurse indicated one of the residents was not “capable.” The report ultimately found the home was in violation for not carrying out an assessment. The home was also found non-compliant after staff hesitated a day to report the alleged abuse to the director, because they were unsure about the nature of the incident.
Peter D. Clark was also cited for a case in which a personal support worker allegedly emotionally and physically abused a resident. (In an interview with the inspector, a registered nurse acknowledged the incident, but said the resident had been known to fabricate in the past.)
The alleged abuse was reported three days later, violating the home’s policy to report abuse cases immediately.
At Garry J. Armstrong, a Jan. 31, 2018 report said the home failed to ensure its policies were properly carried out after a resident fell and died on the same day.
After the resident failed to show up for lunch, a personal support worker found the resident fallen on the floor, according to the report. One nurse interviewed said whenever a fall is unwitnessed — as it was in this case — a head injury inspection should be done.
The report is unclear as to whether or not the resident died from the fall. Ultimately, however, the report determined certain protocols regarding a medical evaluation of the resident were not documented and completed correctly, and the resident’s motor response or pupils were never assessed before their death.
In a Feb. 9, 2018 report, a personal support worker witnessed a resident touching another resident inappropriately on an unspecified date in 2017 at Carleton Lodge.
The worker told a ministry inspector that she “believed that the incident was sexual abuse, however, she did not report the incident immediately” because she had “gotten busy with other residents and forgot to report the incident.”
The worker was then off for two days and said she remembered the incident and reported it once she returned to work.
By neglecting to report the reported case of abuse immediately, the ministry found the home had failed to ensure that its own abuse policy was followed.
“The City of Ottawa stands firm on its commitment to continuous improvement in the delivery of care for our residents and to ensure a healthy and safe environment,” said Janice Burelle, the city’s community and social services general manager, in an emailed statement. “Part of that commitment includes the actions implemented between October 2017 and January 2018 as outlined in the five work plans provided to the province in the fall of 2017.”
Those actions include items such as enhanced staff training on the prevention of abuse and neglect and an “additional management presence” on evenings and weekends that includes checklists and followups.
There are also new tools to help staff assist residents from “diverse cultural backgrounds.”
As well, an independent third-party reviewer is conducting an assessment of the city’s four homes to provide recommendations aimed at preventing incidents of abuse. The report will be completed by the end of April 2018.
“Concrete actions will be developed and implemented stemming from these recommendations,” Burelle said.
When reached for comment, the Health Ministry said it “is continuing to meet with the City of Ottawa on a monthly basis” and is receiving “progress reports to maintain close monitoring of actions being taken locally.”
The ministry also said the ability to levy financial penalties against homes repeatedly found non-compliant with provincial rules is closer to fruition — a long-sought request from long-term care advocates. The ability to fine homes was introduced in legislation last December, but is currently not available as the government awaits public feedback on draft regulations.
Following input from the public, which can be done until the end of March, the ministry will “communicate with the long-term care sector about the new penalties and how they will be used to strengthen enforcement and achieve compliance with operators where recurring issues exist.”
Do you know more about the incidents detailed in this story? Contact our reporters.
amah@postmedia.com
Twitter.com/alisonmah
dfenton@postmedia.com
Twitter.com/drakefenton
查看原文...
