Series on Health Care for Elderly, Part 1
'Interim care' Places Elderly at Risk: Chief Coroner

Death of 92-year-old transferred from hospital due in part to inadequate care at retirement home, report finds

By Pauline Tam, The Ottawa Citizen

February 16, 2010

Canada

A 92-year-old Ottawa woman who was transferred from the Queensway Carleton Hospital to a privately run retirement home died in part because of inadequate care there, says the province's chief coroner, who warns the practice could put other elderly patients at risk.

In his most recent report on geriatric and long-term care, Dr. Andrew McCallum details an investigation by his office into the 2008 death of the unnamed woman.

The report does not identify where she lived, the hospital where she was treated, or the retirement home where she was moved. But the Citizen has confirmed the particulars of the case through Jane Meadus, the lawyer representing the woman's family, which gave permission for some of the identifying details to be published.

According to McCallum's report, some Ontario hospitals, in an effort to free up beds for surgical and emergency patients, are experimenting with discharging elderly patients to unlicensed retirement homes, even though they are not always equipped to provide the same round-the-clock care as provincially regulated nursing homes.

The idea behind such "transitional care" or "interim care" programs is to tackle an expensive and vexing problem facing hospitals, which are seeing an increasing number of elderly patients who don't belong in hospital beds, yet languish there for months until nursing-home spaces are available.

As a result, people who are actually sick can't get hospital beds, leading to overcrowding in emergency rooms and cancelled surgeries.

In a June 2009 letter to the Ontario Hospital Association, McCallum cautioned against shifting elderly patients awaiting nursing-home beds to retirement homes. And he repeated the warning three months later in his geriatric and long-term-care report.

At the time the woman died, the Queensway Carleton was one of the institutions testing such a transfer program.

Between May 2008 and December 2009, when the trial run ended, the woman was one of 250 Queensway Carleton patients who were discharged to the Prince of Wales Manor, a retirement home in the city's southwest.

During much of that period, the Prince of Wales Manor was not licensed as a nursing home, meaning it was not obligated under provincial regulations to provide the same standards of care.

Over 19 months, some $2 million in public funding went to the Prince of Wales Manor on the understanding that the money would be used to pay for up to 30 temporary beds -- as well as the staff and services to provide the "equivalent care" of a licensed nursing home. The money came from the Queensway Carleton and the Champlain Local Health Integration Network (LHIN), Eastern Ontario's health authority.

In addition, the Prince of Wales Manor received co-payments from each patient who was transferred there. The payments, up to $19,000 a year per patient, were equivalent to the base rate for a licensed nursing-home bed.

Dr. Robert Cushman, chief executive of the Champlain LHIN, acknowledged receiving "a few complaints" about care gaps at the Prince of Wales Manor around the time that the woman was transferred there. "In a particular instance or two, the patient care wasn't up to standard," Cushman said.

Given that the project was a trial run, the agencies involved -- the hospital, the retirement home and the LHIN -- were constantly gathering feedback from patients and their families, said Cushman.

He indicated that even before the coroner raised his concerns, the agencies were already looking for ways to improve the care at the Prince of Wales Manor. "We took this matter very seriously, and improvements were made all along the way."

Frank D'Amato, owner of the Prince of Wales Manor, said even though the facility was not officially regulated by the provincial health ministry at the time, "we were aware of the standards and our goal was to meet all the ministry standards."

For example, provincial regulations require nursing homes to have a registered nurse on duty 24 hours a day, seven days a week. At the Prince of Wales Manor, said D'Amato, the facility had several registered practical nurses -- with less training than registered nurses -- working "around the clock" in the areas where the former hospital patients were housed.

Also on staff were a registered nurse, a physiotherapy team and "numerous" personal support workers -- "way higher staff levels than we would ever have at a regular retirement home," said D'Amato.

On average, each patient received the equivalent of three hours a day in nursing care, which was higher than the provincially mandated average of 2.5 hours a day per patient, said Gary Harper, director of operations at the Prince of Wales Manor.

In the case investigated by McCallum's office, the elderly woman died in September 2008, two months after being transferred to the Prince of Wales Manor. At the time, she suffered from dementia, diabetes-related complications and several other chronic conditions. Over two weeks at the retirement home, the woman's health steadily worsened, prompting her daughter to draw up a list of complaints that she brought repeatedly to staff at the facility. Her pleas did not appear to improve her mother's care, the report noted.

On July 30, the woman was re-admitted to the Queensway Carleton suffering from low blood pressure, dehydration, malnourishment and pain that had not been properly treated. On Sept. 10, after a week of palliative care, she died in hospital.

The coroner's report did not fault the hospital for the care it provided the woman. But given her already frail condition, the hospital should never have moved the woman in the first place, the report concluded.

"Upon review, it was evident that the private care home did not possess the expertise, care and services necessary to provide for the woman's significant care needs," the report stated. "Retirement homes have lower staffing ratios than long-term-care homes and it is hard to imagine how a private retirement home could meet the care needs of a resident like this woman without significant staffing enhancements."

Maureen Taylor-Greenly, the Queensway Carleton's chief nursing executive, said patients are screened carefully to determine if they're suitable for discharge to retirement homes. Typically, she said, the hospital also consults case managers from the Champlain Community Care Access Centre, the agency responsible for home care and nursing-home admissions.

But the union representing 2,000 long-term-care employees, including those working in retirement homes, has questioned whether staff at those facilities are properly trained to care for discharged hospital patients. "For a long time, our members have been warning us that, 'Look, we're getting people in here who really should be in nursing homes'," said Rick Janson, spokesman for the Ontario Public Service Employees Union.

Meadus, a Toronto lawyer who specializes in elder-care issues, said she has heard from several families who have felt pressured by hospitals to discharge their elderly relatives to unlicensed retirement homes.

"They go and see them and the homes do tend to look pretty good," said Meadus, of the Advocacy Centre for the Elderly. "The problem is that you get in there and, of course, they can't provide the kind of care, they don't have the services, (the staff) aren't trained, and there (is) no one to complain to."

Meadus said some hospitals, in their haste to discharge elderly patients, have told families that if they refused to accept the transfer, they would have to start paying up to $700 a day for their relative to remain in a hospital bed.

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