How 17 people in Ottawa long-term care died
At least 17 people have died in Ottawa long-term care homes since 2012, with the care they received before their deaths leading to findings of non-compliance with provincial legislation, an investigation by this newspaper reveals.
On Monday, this paper documented how there have been 163 reported cases of abuse and 2,033 instances of non-compliance since 2012 at Ottawa’s 27 long-term care facilities. This newspaper gleaned its data from reviewing thousands of pages of Ministry of Health and Long-Term Care inspection reports.
A facility can be found noncompliant for different reasons. Some are minor, such as a failure to offer a resident a snack. Some can be serious, even when no resident is harmed, such as leaving an exit door unlocked. And some are very serious, such as cases involving abuse and death.
The following is a breakdown of the 17 deaths uncovered by this newspaper’s istry documents. examination of min-
1.
at the In Perley September and Rideau 2013, a Veterans’ resident Health Centre was transferred to The Ottawa Hospital, then returned to the Perley several days later. In the documentation sent back from the hospital to the Perley, the hospital resident physician noted: “Narcotics were discontinued given their likely contribution to the patient’s respiratory problem.”
The phrase “no narcotic” was also included in the diagnosis section of the hospital’s progress notes. A nurse at the Perley picked up the documents at a fax machine, showed them to another nurse,
then put them in the resident’s file without reading them.
The resident was breathing normally and their vital signs were stable when they were returned to the Perley. That night, however, the on-call physician ordered the resident to receive a dose of narcotic four times a day. The resident had personal the than By resident received usual. the next support to two morning, be “less worker doses responsive the when found resident a unresponsive was found to to voice, be “completely touch or pain.” At 7:45 a.m., the Perley called 911 and the resident was returned to hospital, where they died two days later. The Perley was found non-compliant with ministry legislation for failing in its duty to protect, according to a report on the incident dated Nov. 22, 2013. It cited failures of communication at the Perley and “significant delay in responding to the resident’s deteriorating clinical condition.”
2. A resident at Residence SaintLouis died three days after suffering an injury following an improper transfer from a bathtub to the resident’s bed, an April 2017 ministry report says. The home was found non-compliant with ministry legislation for failing to ensure staff used a safe transferring technique when moving a resident.
The resident had a history of thrashing about suddenly. Following the transfer from the bath, “The resident had a sudden identified movement and hit (an) identified body area on the metal support of the bed equipment,” the report says. The report does not say what body part was injured.
The resident was taken to hospital and died three days later.
The resident had been positioned on the bed improperly, the report says.
“The bed was placed in a way that when the resident was transferred with the ceiling lift, the transfer only allowed to have the resident identified body area positioned in a certain way in the bed.”
The support worker who transferred the resident was asked why the resident was placed in this manner instead of facing the opposite direction. The support worker responded that she didn’t think she was allowed to change the direction of the bed.
3.
Staff at Villa Marconi, on Base- line Road, were not provided with clear instructions on how to properly care for a resident identified as being at risk of choking.
The resident would later die following a dinner service, a February 2017 report says.
The ministry report does not specify how the resident died, nor does it specify when the resident died. The report only says the resident died after an “incident” that caused “distress” during a meal. However, the home was found non-compliant with provincial legislation for not providing staff with clear instructions.
4.
Over a period of days in August 2015, the health of a resident at the Glebe Centre slowly deteriorated, unbeknownst to the resident’s family.
The resident suffered a series of falls and no post-fall assessments were conducted, a March 2016 ministry report says.
The resident was reported to be mostly independent before the series of falls began. But then one day, at some point after a fourth fall, the resident was not acting normally. tated By was And lunch, “teary and by suppertime the pacing The and resident resident mumbling” in the the felt morning.” was resident weak. and “agi- so weak longer that even the hold resident a cookie. could no
The resident’s family was not informed of this, the report says.
Eventually, a family member suspected something was not right and called the resident’s physician to request they call the home to ask about the resident’s health.
The physician visited the resident, ran some tests, and “suspected a specific type of infection.” The physician informed the family and the family went to visit the resident. They requested the resident be sent to hospital. The resident died in hospital two days later.
For its handling of the situation, the home was slapped with three non-compliance orders for not following provincial legislation.
5.
A personal support worker was showering a resident at the Salvation Army Grace Manor who was not supposed to be showered, a February 2016 ministry report says. When the support worker turned around to grab a towel, the resident, who was not wearing a seat belt, fell forward, suffering a laceration and a fracture. After the fall, the resident was non-responsive, not breathing and had no pulse. A nurse began CPR. However, the nurse was not aware that the resident’s spouse had recently conducted “long conversations” with a physician about the resident’s end-of-life treatment as the resident had recently returned from hospital after opting not to have surgery and instead “receive comfort care only.” The resident had a Do Not Resuscitate order upon return from hospital and the home was aware of this. However, the nurse was not. Nor were two other nurses who were on hand following the fall. The home was levied with two non-compliance orders for not following provincial legislation, both for not properly following the resident’s care plan.
6.
A resident at Forest Hill in Kanata choked to death during a meal, a July 2013 report outlines. Staff members at the home noticed the resident had previously struggled eating, but decided to monitor the situation further.
Eventually, staff members recommended a change to the resident’s diet as a preventive measure. The next day, before the changes were implemented, the resident choked to death. The home was found non-compliant with provincial legislation for not having the resident’s plan of care updated to reflect any “risks related to nutritional care.”
7.
Residence Saint-Louis was found non-compliant with provincial legislation multiple times for different failures in 2015, all for its mishandling of a single resident who was abused in September before dying of a heart attack in December.
In September 2015, the resident was punched by another resident during lunch, a September 2016 ministry report says. Following the attack, the resident “was very emotional, stating that he/she was not used to being battered.”
The home was found non-compliant because the resident’s family was not notified of the abuse.
The resident’s year in the home only got worse. On a day in December, the resident began complaining about stomach pain, the same September 2016 ministry report says. The resident refused to go to hospital when offered by staff. Hours later, the resident was dead from a heart attack, the report says.
The resident was found without vital signs by staff. A nurse immediately began CPR, despite a Do Not Resuscitate order in the resident’s file. The home was found noncompliant for not following the resident’s care plan in relation to the DNR order and was also found non-compliant because the home’s director was not immediately informed of the resident’s death.
8.
A resident at Hillel Lodge was transferred from bed by a personal support worker with the incorrect mechanical lift, a November 2014 report says.
During the transfer, the resident fell to floor, fracturing a hip and sustaining a head injury. The resident died the next day. The home was found non-compliant with provincial legislation for not safely transferring the resident.
9. A resident at Sarsfield Colonial Home took a hard fall, fracturing a bone, a January 2014 ministry report says.
Four days later, the resident died.
The report doesn’t specify the severity of the fracture, nor does it specify a cause of death. However, a ministry inspector found that “no post-fall assessment was conducted using a clinically appropriate assessment instrument specifically designed for falls.”
The report also does not specify if the resident had a history of falls.
The home was found non-compliant with provincial legislation for failing to ensure “there is an interdisciplinary falls and management program to reduce the incidence of falls and the risk of injury to residents.”
10. Extendicare Starwood’s director of care waited six days before informing the home’s director that the “unexpected death” of a resident had occurred, says a July 2014 ministry report.
After being found on the floor of his/her bathroom with two small tears on the right arm and a “large hematoma” on the forehead, the resident was found without a pulse in his/her chair later that same day.
The report does not specify the cause of death nor mention if the resident experienced any previous incidents.
The home did not comply with provincial legislation to ensure the director was immediately notified of an unexpected death.
11. Nursing staff at Manoir Marochel failed to properly monitor changes in a resident’s deteriorating condition after the resident suffered a head injury from a fall.
The resident died three days later, with an August 2013 ministry report saying the fall resulted in “actual harm and eventual death.”
12. A resident at the Perley and Rideau Veterans’ Health Centre choked to death in the home’s dining a room, an April 2016 ministry report says.
The resident had a care plan that indicated if something were to go wrong, CPR would be attempted by staff and an ambulance would be immediately called for transfer to hospital.
This did not happen, the report says.
After the resident was found slumped over at the dinner table, a support worker and food aid rushed to get a nurse. The nurse began abdominal thrusts. The head nurse arrived on scene, assessed the resident, and said the resident did not have a pulse and was not breathing. The head nurse eventually told the nurse performing abdominal thrusts to stop. The head nurse said it would be “futile” to perform CPR, the report says.
The home was found non-compliant with provincial legislation for not performing CPR and for not calling an ambulance.
13. In January 2015, a night shift worker at Peter D. Clark Centre noticed that a resident had “altered skin integrity.” The resident was taken to hospital and died the next month, according to a March 2015 ministry report.
The personal support worker said barrier cream had been applied to the affected skin area and a nurse informed, but investigators found no record of this. Although a number of PSWs said the resident’s skin problems had been ongoing, several nurses at the home told investigators that they “were not aware or ever notified of the severity of the altered integrity” until the day the resident was sent to hospital. Administration at the centre concluded the fault was a “failure of communication” between the personal support worker and nursing staff.
The ministry found that the resident “did not received immediate treatment and interventions to reduce or relieve pain, promote healing, and prevent infection” and issued a non-compliance order for its skin and wound care.
14. A palliative care resident died days after being attacked by another resident during lunch at The Glebe Centre, says a March 2016 ministry report. While the report says the resident “passed away four days after the incident not related to the injury,” the report does not specify the resident’s cause of death, nor does it say if the attack led to a worsening in conditions. The home was found noncompliant with provincial legislation for not protecting the resident from abuse, just four days before the resident’s death.
Previously reported deaths in long-term care facilities:
This newspaper has previously documented three other incidents in Ottawa long-term care facilities that led to non-compliance orders before the resident’s death. Those residents were Marcel D’Amour, a former Residence Saint-Louis resident who died in 2015; Rita Normoyle, a former Extendicare Laurier Manor resident who died in April 2016; and Violet Lucas another former Extendicare Laurier Manor who died in April 2017.