Care homes’ lax drug controls revealed
Lax drug controls and an unreported act by a resident known for inappropriate sexual behaviour were revealed during investigations by the city’s auditor general at city-run long-term care homes.
The findings were part of an audit released Monday during a council audit committee meeting.
Auditor general Ken Hughes didn’t identify the long-term care home where the sexual incident happened, or the exact date, although it happened in 2017.
According to the findings, a male resident known for inappropriate sexual behaviour was found in his room trying to position himself on a female resident who was in a wheelchair. Staff notified the oncall manager, who didn’t believe the incident met the sexual abuse parameters required for notifications to police and the Ontario Ministry of Health.
The next day, another nurse learned about the incident and was concerned authorities weren’t contacted. The nurse gave the oncall manager more details and they agreed police and the ministry should be called.
The male resident, whom the auditor described as a “known risk,” was subsequently moved to an allmale section of the facility.
The auditor’s office found discrepancies in the policies on reporting alleged abuse to the police and to the province. The incident should have been immediately reported to police and the ministry, the audit concluded.
City manager Steve Kanellakos told reporters the ministry “didn’t find anything wrong with how the incident was reported (or) when it was reported.”
Kanellakos said he has faith in the staff who work in the city ’s the long-term care homes.
“I do have faith because there’s over 700 residents in those homes. (Staff ) make thousands of decisions every day for people that are in that home. One person can make an error in judgment and not communicate it appropriately and cause an issue. That happens in life. That happens when we deal with people,” Kanellakos said.
The city also said police didn’t conclude there was abuse.
Hughes made 10 recommendations based on his investigation into how the city handled the case. City management said it agrees with all the recommendations.
The auditor general decided to launch an investigation last summer after learning of troubling incidents at city facilities. The city has four long-term care homes: Garry J. Armstrong, Peter D. Clark, Centre d’accueil Champlain and Carleton Lodge.
The report also looked at medication control at the city facilities, concluding there’s a big risk of “drug diversion,” or theft, at longterm care homes.
The audit, which looked specifically at the Peter D. Clark and Garry J. Armstrong homes in 2016 and 2017, revealed there were poor controls over the medication stored at the homes.
“What we found was the processes and policies that are in place are in conformity with the legislation, but a lot of the procedures are not being followed,” Hughes said. “There’s no one checking on a regular basis that all the procedures are followed.”
That means medication could be lost or stolen, he said.
In some cases, staff signatures on drug documents couldn’t be identified by auditors.
When it comes to emergency drug supplies, there was poor documentation about why drugs were removed. There was also little evidence to show there were periodic reviews of the stock.
The audit discovered there were no video cameras in medication storage areas. There was lax security from the time the medication arrived to the dispensing and the disposal.
Janice Burelle, general manager of community and social services, said the city will review Hughes’s suggestion to put cameras in the medication storage rooms.
“We will be considering them going forward,” Burelle said. She noted that the finance and economic development committee on Tuesday will consider spending $1 million on technology upgrades at long-term care homes.
The city’s corporate security could give the long-term care program pricing for the video cameras.
Hughes said the audit discovered there’s no enforcement of medication procedures, noting he’s most concerned about the controls on the emergency supply. “The policies are adequate. They are just not being followed,” Hughes said.
Dean Lett, the city ’s head of longterm care, said that when medications now arrive at the home, they’re locked up immediately until the appropriate staff can pick them up. The auditor general didn’t calculate a monetary estimate on potential losses of medication.
City management agreed with all 17 recommendations the auditor’s office made regarding control of medication.
“It was really sad and disturbing to read some of the findings in the audit report,” Osgoode Coun. George Darouze said, encouraging city management to closely look at the medication-related audit. “There is no room for mistakes when we administer drugs to our seniors.”
An independent review of cityowned long-term care homes was also released Monday during a community and protective services committee meeting.