CHANGES AT CARE HOME
Family hopes report means big improvements
Jackie Lewis says the provincial ombudsman’s report on her mother-in-law’s death should be a wake-up call for all long-term care facilities in Saskatchewan.
Ombudsman Mary McFadyen conducted an investigation into the events at Extendicare Sunset leading up to and after Jessie Sellwood’s death.
Sellwood fell while being helped by a care aide on Dec. 23, 2013.
The 87-year-old was taken by ambulance to the Pasqua Hospital emergency room, given pain medication and stitches and sent back to the care home.
Two days later, Sellwood was complaining of pain and nausea and her leg was swelling. On Christmas Day, she was taken back to the hospital and diagnosed with a broken leg, given pain medication and an anti-nauseant and returned to Sunset. She died on Dec. 27, 2013.
Her family had questions about her care and was frustrated with the responses they received.
McFadyen’s report outlined several issues including:
Gaps related to fall prevention at Extendicare Sunset and a lack of awareness of some of the gaps.
Questions about whether communications between Sunset, the ambulance and the ER were as complete as they could have been.
Delays in reporting the death to the coroner, including a lack of awareness about when to report a death to the coroner.
Review processes were conducted in isolation. None looked at all aspects of care at Sunset, the ambulance and the ER.
A lack of understanding about what information could be provided to immediate family following Sellwood’s death.
A lack of meaningful and timely answers to the family’s questions.
McFadyen noted the Ministry of Health has “fairly good guidelines” for long-term care facilities.
“It’s not only important that guidelines are put in place, but we actually ensure that our longterm care homes are meeting those guidelines and that there is some public accountability,” she said.
For example, Sellwood’s fall risk should have been reassessed after she moved into the home.
“She was only assessed as being a one-person lift and she was helped by one care aide and that is when she did fall,” McFadyen said.
Because Sellwood’s death was associated with a fall in a longterm care facility, Sunset should have deemed it a critical incident within three business days, or as soon as possible, and reported it and reviewed it under The Critical Incident Regulations.
It wasn’t until May 27, 2014, that the Regina Qu’Appelle Health Region deemed it a critical incident — five months after Sellwood’s death. That was when the coroner was contacted.
McFadyen noted the proper investigation wasn’t done at Sunset and there was a lack of communication between the region and the home.
The family was entitled to see Sellwood’s entire chart and had asked for it, but they didn’t get it for five months.
“No one seemed to know that this was the law,” McFadyen said. “There are good things in place to make sure that families get information, to make sure unexpected deaths are investigated, but we have to make sure that they are put in place and monitored to make sure that they are working.”
McFadyen acknowledged that both the health region and Extendicare accepted the recommendations and are in the process of implementing them.
She went through the final report with Sellwood’s family Thursday prior to its release.
The family is thankful for the ombudsman’s thorough work, Lewis said.
“God help us if anybody else has to go through this,” she said. “Is this the health system that we want for when we get older? ... It’s not right. I hope it wakes people up.”
NDP health critic Danielle Chartier said the report adds “to the growing body of evidence that minimum care standards are required in Saskatchewan.”
“The Saskatchewan Party needs to ensure that health regions and long-term care facilities have the resources to meet those standards,” said Chartier, who added that LTC facilities are short staffed across Saskatchewan.
McFadyen called on senior officials with the RQRHA and Extendicare Canada to apologize to the family and explain changes they have made or will be making.
Sunset’s administrator Kim Skinner said CEO Tim Lukenda sent the family a letter of apology and a list of improvements on July 11. Improvements include instituting a fall management program and a revised process to report critical incidents.
The Ministry of Health and all health regions completely reviewed and revised the special care home guidelines, said Gretta Lynn Ell, the region’s executive director of Continuing Care.
With the revised guidelines, the ministry developed DVDs to train staff in every LTC facility in the province about the standards of care, Ell said.
All of the facilities must report monthly the number of staff trained.
The region will be sending a letter of apology to Sellwood’s family.
Sellwood’s children are suing the health region and Extendicare Sunset. Filed on Friday by Regina lawyer Tony Merchant, the lawsuit seeks general and punitive damages.