FAMILY IN DARK OVER NURSING HOME INJURY
Phillip Kennedy, 81, moved into Hawthorne Place, a long-term care centre, late in 2017. Three days later, he was found with a deep gash to his leg. The facility has since fired five workers but Kennedy’s family still doesn’t know exactly how he was hurt
It’s been more than a year since 81-yearold Toronto nursing home resident Phillip Kennedy suffered a leg wound so deep and wide it looked as if he had been sliced open by an axe.
His daughter, Kathleen Kennedy, said the home has never told her family how Phillip was injured, even though it happened in the middle of the day, in a licensed Ontario long-term care facility busy with nurses and personal support workers.
When Phillip was injured — three days after moving in — nobody from Hawthorne Place Care Centre could, or would, say how it happened. A provincial ministry of health inspector spent six days investigating but found no explanation for the cause of the injury. Phillip died in hospital three weeks later. Kathleen said his death report cited end-stage heart disease and kidney failure.
“If they had just said to me, ‘you know what, we dropped him,’ or even, ‘you know what, he was hit with an axe, we are sorry and this is what we’ve done to make sure it doesn’t happen to some- one else,’ I would have accepted it. But there was none of that. Nothing,” Kathleen said. “It is very unsettling.”
After Phillip was injured, on Oct. 28, 2017, the inspector interviewed at least eight employees, including the home’s administrator, physiotherapist and personal support workers. While the inspector’s final report, provided to the Star by Phillip’s family, didn’t find conclusive answers, it detailed four violations, including the “abuse and neglect” that led to the firing of five workers.
The report also found unsafe practices while moving him from sitting to standing and from chair to bed.
Last week, a spokesperson for Hawthorne Place Care Centre told the Star that its internal probe, including the work of an outside investigator, found that Phillip’s injury was likely the result of a staff error.
“All indications are that the injury was unintentional — the result of an accident which occurred while the resident was being cared for by our staff,” the emailed statement said. “This is a highly regrettable incident, and we apologize without reservation to the resident's family.
Kathleen said this is the first she has heard of the home’s findings.
Hawthorne Place is owned by Rykka Care Centres. Its managing partner, Responsive Management Inc., said the nursing home could not go into any additional detail because of “pending legal action” by the family. Last spring, Kathleen, a registered nurse, hired a Toronto law firm to look into her father’s case.
The family’s troubles began more than a year ago, after Phillip was discharged from a Richmond Hill hospital where he had spent two months after repeated falls, along with heart problems.
On Oct. 25, 2017, Phillip moved into a shared room on the first floor of Hawthorne Place, a long-term care home built in the early 1970s near Jane St. and Finch Ave.
His time there was expected to be short, just to get him steady on his feet again, so he arrived with little more than his clothes and rosary beads. Though he struggled with his balance, Phillip’s mind was sharp and he loved to read, always with a newspaper or the BBC History magazine by his side.
Three days later, a personal support worker found Phillip lying in bed, his sheets stained with blood, the worker told the inspector. A deep slash in his leg cut to the bone. Staff huddled outside his room, entering and leaving, as he lay in bed, his eyes closed, murmuring in response to a nurse’s question: “Are you okay?” The nurse could not hear what he said.
That afternoon, Greg Kennedy, Phillip’s son, was driving with his mom to visit his dad when nursing home staff called to tell him of the injury.
“When I got there, he was in bed and his leg was bandaged,” said Greg, a supervisor at Molson Coors, currently on disability leave. “There were five workers standing outside his room and nobody could say what happened. He was incoherent. He looked awful. He was grey, a kind of death look.
“I was in tears when I left there. I thought he was going to die right then and there.”
Greg said the paramedics who rushed Phillip to Humber River Hospital told his family to file a complaint with the ministry about the severity of the injury and staff’s inability to describe how it happened. Kathleen contacted the ministry, and a few days later the inspector arrived to investigate.
The home’s administrator told the inspector that “discrepancies were found emerging from staff interviews.”
Staff didn’t immediately report the injury to the ministry or police, as is required when abuse is a possible cause. After the home’s administrator learned of Phillip’s condition two days later, the ministry and police were contacted, the report said. Kathleen and the administrator separately reported the injury to Toronto Police, who told the Star officers interviewed “at least two staff members” but could not confirm how Phillip was injured. Police closed the case in January.
Hawthorne Place fired the two personal support workers and three nurses who were involved in Phillip’s care that day, the report said. The nurses were reported to the College of Nurses of Ontario, the oversight body for nurses. A college spokesperson confirmed the nurses are being investigated.
Photographs taken by Greg show the gash was on the outer part of Phillip’s right leg, just below the knee. It was a deep, gaping wound.
The timeline of Phillip’s injury and how staff reacted to it are detailed in the ministry report.
At roughly 2:30 p.m. on October 28, a personal support worker called a registered nurse to Phillip’s room, pointing to blood on his bed sheet. When the worker rolled up Phillip’s pant leg, the nurse saw a “large laceration” on his outer right shin. The nurse reported seeing “some white stuff, appeared like bone.”
This registered nurse left Phillip without assessing him, the inspection report said, and went to ask another nurse to measure and cover the wound. The first nurse called the ambulance and Phillip’s family. Nobody called the police or ministry.
The second nurse went to another part of the home to find a measuring tape before arriving in Phillip’s room, later telling the ministry inspector the wound was “deep with sloughs and it was so bad (she/he) could not look at it to measure the wound.”
This second nurse left Phillip’s room without assessing him, the report said, and went to find a third nurse.
The third nurse arrived and measured the wound at five centimetres by five centimetres, and covered it with gauze and a bandage. Kathleen said she believes the wound was larger.
The ministry inspection report said the three nurses and two personal support workers directly involved “denied any knowledge” of the cause of the injury, with staff saying it likely happened between Phillip’s lunch and 2:30 p.m.
While the inspection report doesn’t conclude what caused the injury, it notes a personal support worker’s admission that she “transferred,” or moved, Phillip on her own, even though his care plan had been updated a day earlier to say he was so unsteady on his feet that he needed two people to help him. (He weighed more than 200 pounds.)
When the inspector later tried to re-create how Phillip had been transferred into bed, she found that her knee pressed against the knob and a flat piece of metal connecting the knob with the sides of the bed rail. The report said the flat piece of metal “was not smooth.” Kathleen said the inspector told her that this detail was considered an observation, not a conclusion of what caused the injury.
The inspector noted that the home’s director of care later “acknowledged the nursing team and the physiotherapy team did not collaborate with each other” in regards to Phillip’s assessments and the requirement he have two-worker transfers.
On the day of his injury, after Phillip returned from the dining room in a wheelchair, the lone worker helped him out of the chair and onto the toilet. Then the worker helped him move to his bed.
The worker later told the inspector that Phillip did not fall during those transfers. The report said the worker acknowledged that an extra person was required.
After the injury and Phillip’s stay in intensive care, his family requested he be transferred back to Richmond Hill’s Mackenzie Health hospital. On Nov. 19, three weeks after his leg wound, Phillip died. Kathleen said the death report cited her father’s ongoing heart and kidney problems.
The law firm, Howie, Sacks and Henry, is talking to the home through its insurance company, Kathleen said. A lawsuit has not been filed.
“This is a shocking injury,” said the family’s lawyer, Melissa Miller. “No family should have to go through this. No resident of a nursing home should have to go through this.”