Daughters seek answers about mother’s death

Woman with dementia died days after sustaining head injury at nursing home

SASKATOON Six days after 82-yearold Frances Sander moved into the Rose Villa long-term care facility in Rosetown, she was found collapsed on her bathroom floor in a pool of blood and urine, moaning and unable to speak, unable to move her right arm and right leg.

Nearly two hours elapsed before she was transported by ambulance to Royal University Hospital in Saskatoon, where a CT scan revealed a serious head injury.

Sander died less than three days later, on Friday, April 13, 2018.

Despite a critical incident investigation — in which the Saskatchewan Health Authority identified “opportunities” for learning and improvement — Sander’s daughters, Rose Botting and Valerie Cey, are left with unanswered questions.

“Opportunities to, like, what? Opportunities to look after people that you’re getting paid for?” Botting said.

“The opportunity was already there,” Cey added.

The two sisters want to know how and why an elderly woman — who had dementia, a history of falling and a plan to prevent more falls — could end up dying from a head injury sustained while in the care of a nursing home.

They have no evidence their mother’s care plan was actually followed that night, they said.

“For me, I want somebody to say, ‘Yeah, we screwed up and we’re really sorry,’ ” Botting said.

Nor do they know if anyone has been held responsible.

“We aren’t allowed to know if anybody even lost a day’s pay over it,” Botting added.

The events are outlined in a sixpage account Botting and Cey sent to the ministers of Health and Rural and Remote Health in early June.

Sander’s daughters wrote that by the time she moved into Rose Villa, their mother had been diagnosed with heart failure and vascular dementia, and needed continuous oxygen delivered through a nasal prong. Sander had already fallen a couple of times while walking on her own using a walker.

However, Sander often forgot it was unsafe for her to get up on her own. In hospital, a bed alarm was frequently activated when she tried to get up, especially during the night when she needed to use the bathroom.

At Rose Villa, a bed alarm was installed and Sander was placed on hourly checks during the night (a practice called night owl rounding). During Sander’s first night at Rose Villa, staff responded to the bed alarm at 3 a.m. and found her on the floor. She was helped back into bed. The next day, it was decided she would be helped to the toilet twice every night, between the hours of midnight and 1 a.m., and between 4 a.m. and 5 a.m.

The toileting schedule and “night owl rounding ” was spelled out in a care plan posted on two message boards in her room. Also included were instructions to set the bed alarm, and to make sure her oxygen was on, fall mats in place, and her walker was at her bedside.

On April 10 at 7:30 a.m., a continuing care aid (CCA) who was just starting her day shift found Sander on her bathroom floor. There was blood on the floor and the toilet, as well as behind her head. A laceration to her right arm had bled a lot.

Sander’s bed alarm “was not reported to have been activated that morning,” according to a summary timeline later given to the family.

The ambulance crew found Sander with a hematoma to her frontal and occipital lobes (a solid swelling of clotted blood in two regions of her brain), along with bruising and swelling to her nose. At 9:20 a.m., the ambulance transported Sander to Royal University Hospital in Saskatoon.

There, an immediate CT scan revealed a large subdural hematoma (collection of blood outside the brain, usually caused by a severe head injury).

It had pushed her brain to one side. The doctor offered surgery, explaining it would need to be done immediately, but if Sander survived her brain functioning would likely be diminished.

The family declined surgery, since Sander had signed a health care directive rejecting extraordinary measures to keep her alive, and instead chose palliative care.

In an interview, the sisters said that although rushing their mother to RUH as soon as she was found may not have produced a different outcome, they believe it would have been her best chance. They are still troubled by several unknowns, including how long she lay on the floor bleeding and what exactly happened between the time she got out of bed and when she was found.

In a written report this month, the coroner attributed Sander’s death to “subdural hematoma due to an unwitnessed fall,” ruled it accidental and said a public inquest is “not necessary.”

Two weeks to the day after their mother’s death, Botting and Cey met with Ruth Miller, director of continuing care for the Heartland Health Region, and Mike Morrill, health care administrator with the Rosetown and District Health Centre.

Cey and Botting write that no critical incident investigation had been initiated by that point — and would not be until April 30, almost three weeks after their mother’s fatal fall.

The sisters said the health minister should have been notified of that much sooner — within three business days, or as soon as possible thereafter, according to provincial regulations.

“We firmly believe that had we not approached the management of Rose Villa on April 27 to express our concerns about the events leading to her death, no investigation would have ever occurred,” Botting wrote in a letter to Laurie Anderson, quality improvement co-ordinator in the Rosetown office of the Saskatchewan Health Authority.

In a statement to Postmedia News, the Saskatchewan Health Authority responded that “the work required to determine whether a situation is a reportable critical incident as defined under the Critical Incident legislation takes time.”

The statement also said that “critical incident reviews are not about assigning blame” and that “(l)egislation is in place to allow providers to safely share their information in order to prevent a similar outcome.”

Botting and Cey wrote in their account that their mother’s chart contained no documentation of the hours leading up to when she was found hurt and bleeding on the bathroom floor, and no documentation of when she was last seen.

They were told Sander’s oxygen tubing and prongs were on the floor outside her bathroom door when she was found.

As for the bed alarm, it was unclear if it had been set.

Sander’s daughters would later read in the summary timeline that “It is unclear if the alarm was turned on, set incorrectly or malfunctioned. It was not investigated post incident.”

Both Botting and Cey, now business owners, had earlier careers in health care. They say they were trained to chart (or log) care provided to patients, in detail.

“Was mom toileted? ... they never clearly said, ‘No, she wasn’t toileted.’ It’s just in the absence of information that we know she wasn’t,” Cey said.

According to investigation interviews with the night CCA and LPN, Sander was checked on between 3 a.m. and 3:30 a.m., and twice again between 5 a.m. and 6:15 a.m. There is no mention of her being toileted.

The Saskatchewan Health Authority wrote in its statement that in many long-term care facilities in the province “only when there is an exception or change to the normal daily routine of that care plan, or a significant change in the patient’s condition and treatment, is it documented on the daily chart.”

Botting and Cey did not receive the summary timeline — the health authority’s account of what happened — until Sept. 25, nearly five months after their initial meeting with Miller and Morrill.

Sander’s family has not received a copy of the investigation report. In a letter dated Oct. 9, Anderson wrote that staff would be educated on “night owl rounding”; audits would be conducted to ensure rounding practices were implemented; care plans would be implemented, evaluated and charted; staff would be provided with work standards and training on charting requirements for client care records; and work standards for bed alarms would be developed, as well as “criterion and standard work for the monitoring and transfer of patient care in the local health centre for long term care staff.”

“Their recommendations were basically to do their job,” Botting said.

In its statement to Postmedia News, the Saskatchewan Health Authority wrote that, as a result of recommendations, LPNS and CCAS at Rose Villa are checking in on new or at-risk residents every hour through the night. “A night owl sheet is by the door and is to be signed hourly after the resident has been visited, and marked with a ‘T’ if the resident was taken to the toilet during that round.” The sheets will be reviewed by the manager and filed by month.

Not satisfied with the responses they have received so far, Botting and Cey have taken their complaint to the provincial ombudsman. After six months of working quietly through the system, they have decided to speak publicly.

“How else will people know that something like this happened?” Botting said. “And will the public know that their loved ones are safe in a nursing home in Saskatchewan?”