Shannex failed resident: report
Complaints in Parkstone death ‘founded’
It's almost two years since Chrissy Dunnington was rushed to emergency from the Parkstone Enhanced Care facility where the 40-year-old woman was a resident. Hospital admission records from Jan. 28, 2018, show she was in respiratory distress with a severe infection from a fist-sized bedsore (or pressure injury) on her tailbone.
Now, the report from an investigation by the Department of Health and Wellness into a complaint filed by her family supports their concerns that she received inadequate care at the Shannex Inc. facility where she was a resident for 14 months before dying in hospital on March 22, 2018.
“After a full investigation, the (Protection of Persons in Care Act) Office has concluded that the reported incidents of failure to provide adequate nutrition, care, medical attention or necessities of life, are founded,” says the report, which has been provided to the family and the nursing home.
“Although staff were completing tasks related to the care of the resident, there were gaps in the overall coordination and oversight of care of the resident, gaps in documentation, gaps in assessments, and limited consultations with internal/external health professionals. Although the facility has comprehensive policies and best practice guidelines available to staff, there was evidence that staff were not following these policies and procedures on a consistent basis.”
Chrissy was born with spina bifida and spent her life in a wheelchair. When her foster parents, the Dunningtons, became too ill to provide care, they moved to Clayton Park so they
and their other daughters could visit Chrissy regularly. Sisters Dorothy Dunnington and Elizabeth Deveau emailed a statement to The Chronicle Herald on behalf of her family asking for a further probe into what led to Chrissy's death.
The family says the report not only indicates Chrissy received substandard care but raises a serious question about Shannex's record-keeping. “Chrissy's family respectfully calls on the police to resume their investigation. They are best placed to get to the bottom of who specifically did what, particularly where there is now a formal finding of failure to provide adequate care including the necessities of life — which also happens to be an offence under the Criminal Code.”
Police closed their criminal negligence investigation into Dunnington's death after receiving a report from the chief medical examiner that said questions around inadequate care were outside his purview under the Fatality Investigations Act. But the issue of whether Shannex's records can be relied upon surfaced because of inconsistencies between what the hospital staff observed when Chrissy was admitted on Jan. 28, 2018, and a note filed by the attending physician at Parkstone.
According to the investigator's report, Parkstone “reported that during the physician's weekly visit on February 1, 2018, the physician was advised of the resident's transfer to hospital and was asked about the last time the resident was seen by the physician. The physician reportedly reviewed the progress notes and noted documentation regarding their January 25, 2018 entry was missing. As such, the physician documented a late entry. It said the physician ‘assessed the resident's coccyx wound on January 25, 2018 and documented no odor in wound, no inflammation or purulent discharge, size unchanged, moderate exudate noted.'”
The doctor's note made a week after the Jan. 25 visit is at odds with observations made by other staff at Parkstone as well as observations from emergency room staff the morning of Jan. 28.
“The hospital admission documentation indicated that the resident was admitted with a large (5x5 cm) coccyx ulcer described as ‘probes close to the bone with terrible smell and small amount of serosang (blood) on dressing.' Staff described the wound as Stage 4 or ‘unstageable,'” says the investigator's report.
It noted that the pressure injury was first identified by Parkstone staff on Oct. 15, 2017, and while dressings were changed regularly, and treatments were modified by the attending doctor over the subsequent months, it did not heal. The investigator was unable to determine whether in-house wound care nurses were called to assess Chrissy on more than one occasion.
“There is minimal documentation on the resident's chart indicating that the wound care trained staff were consulted regarding the resident's wound care treatment,” says the investigator's report.
It also found gaps in the coordination of other services. By Nov. 16, 2017, the report says the physician noted the pressure injury on the tailbone was now Stage 2 and the home should consult occupational therapy to change the cushion in the wheelchair. But that action wasn't taken until December when a physiotherapist arrived to assess Chrissy as part of the annual update to her care plan.
An increase to a nutritional supplement ordered by a dietician in November 2017 was not implemented until Jan. 12, 2018 — some 52 days later — because it didn't get added to Chrissy's medication record. She had lost weight over the fall while receiving chemotherapy treatments for breast cancer.
Despite the ongoing support of the Dunnington siblings who took her to chemo appointments, all decisions regarding Chrissy's medical care were entrusted to the Office of the Public Trustee. That's because Chrissy was never formally adopted.
The investigator's report lays out differing and troubling interpretations of why there appears to have been a Do Not Resuscitate Order on Chrissy Dunnington's file. The Dunnington sisters say hospital staff told them a DNR order was on her medical record when she was admitted. If so, how it got there remains unexplained. The Department of Health and Wellness's investigator interviewed the trustee responsible for Chrissy's care about whether she had sanctioned an end-of-life directive.
“The Public Trustee reported that during the Dec. 5, 2017 Care Conference, Parkstone Enhanced Care staff indicated that the resident had a Pathway of Care, which was ‘No CPR.' The Public Trustee reported that they have no authority to consent to a ‘Do Not Resuscitate' order and therefore does not consent to such orders on a client's behalf," said the investigator's report.
"The Public Trustee reported that consent was requested for typical personal and nursing care and medications and included a service plan that was identical to the one received a year earlier (except for an additional intervention added by the dietitian for a nutritional support). The Public Trustee reports not being informed of significant changes in the resident's condition in December 2017 and January 2018 and were therefore unprepared for the multiple infections (pneumonia, sepsis, osteomyelitis, influenza) that were diagnosed in hospital and the drastic deterioration of the coccyx wound.”
The family has sharper words. “Chrissy would not have died that miserable, frightening, painful death were it not for a series of errors and inadequacies in her care at Shannex,” says the statement from the Dunningtons. “Chrissy's family also respectfully calls on the medical examiner to review all evidence, including this new investigative report, as there is already, and will be, much more evidence than the ME first considered.”
Chief Medical Examiner Matthew Bowes filed a report last September declining to recommend police pursue criminal charges, but noted: “The important point to be made here is that the criminal justice system is at liberty to fulfill its mandate irrespective of the determinations of the medical examiner."
The Health Department investigator issued 11 orders or directives to Parkstone, many related to how the facility documents care and medications provided to its 194 residents. While acknowledging Chrissy had complex medical needs, the report said Parkstone must improve how it delivers wound care to mirror the provincial policy which came into effect a year after Chrissy died.
Shannex says it is already acting on the concerns raised. “This is an experience we never want for residents and families who are part of our communities and we take this report and its directives very seriously. Our thoughts continue to be with the family," Shannex senior vice-president of operations Catherine MacPherson said in a written statement Monday.
"In the nearly two years that have passed, we have completed a significant review of our practices and implemented a number of enhancements. Now that we have the report, we have begun a detailed review to ensure that the actions associated with each directive are in place. As part of this process, and respecting individual resident confidentiality, we have engaged with residents, families and our Parkstone team to review our completed work, the report's directives and hear their feedback on how we can continue to improve. This process began immediately upon receiving the report last week and is a top priority for us."
Shannex has provided updates to the Department of Health and Wellness throughout the investigation, MacPherson said.
"These updates relate to actions we have already taken as a result of our own comprehensive review. In May 2018, we introduced a Quality Improvement Plan in Wound Prevention and Management (QIP) that brought forward further improvements in areas such as reporting and management of wounds, communication with residents and families, leadership and training, technology and accessing support from external experts."
The company "will ensure a comprehensive response is provided to the department in accordance with the timelines provided," she said.