Series on Health Care for Elderly, Part 2:
Death Shows Health Care Loophole

Woman, 92, was unfit to go to retirement home: Report

By Pauline Tam, The Ottawa Citizen

February 17, 2010

Canada

The case of a 92-year-old Ottawa woman who died after being moved from the Queensway Carleton Hospital to an unlicensed retirement home shines a light on a health-care grey zone that has existed since at least 2008, when Ontario hospitals started experimenting with such transfers.

As part of a test project by the Queensway Carleton, the unidentified woman was one of 250 patients discharged to the Prince of Wales Manor, a private Ottawa retirement home.

Between May 2008 and December 2009, about $2 million in public funding went to the Prince of Wales Manor.

The money came from the Queensway Carleton and the Champlain Local Health Integration Network, Eastern Ontario's health authority. In addition, the retirement home received co-payments from each patient transferred there.
The payments, up to $19,000 a year per patient, were equivalent to the base rate for a licensed nursing-home bed.

During much of that time, the Prince of Wales Manor was unlicensed, meaning it was not controlled by the government and was not required to have trained medical staff -- nor the appropriate equipment and facilities -- to look after elderly patients needing round-the-clock care.

Details of the woman's case are public through the 2009 report on geriatric and long-term care issued by the office of the province's chief coroner, Dr. Andrew McCallum.

According to the report obtained by the Citizen, when admitted to hospital in June 2008, the woman had a cough, fever and leg pain. Tests showed she had an infected right heel and newly diagnosed diabetes.

She had already been diagnosed with dementia, arthritis, failing eyesight and other conditions that left her wheelchair-bound and largely unable to care for herself.

At another retirement home, the woman had received weekly visits from home-care workers who bathed, dressed and groomed her.

Her daughter, recognizing her mother's increasing need, had applied to have her admitted to a nursing home and was waiting for a bed.

While her mother was recovering in hospital, the daughter was told about the Prince of Wales Manor program.

In July 2008, despite nagging doubts, the woman's daughter agreed to have her mother transferred there, the coroner's report noted.

Almost immediately, the daughter noticed problems, which she documented in detailed notes.

Among other things, her mother was fed the wrong food, deprived of regular nursing and physician assessments, given her medication too forcefully and provided with poor pain management.

Despite repeated complaints to the home, the daughter watched her mother grow more tired. She didn't eat or drink enough, and she complained about pain. Employees at the home admitted to the daughter that the facility was short-staffed, according to the coroner's report.

Finally, 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, 2008, after a week of palliative care, she died.

Although the coroner's report determined the woman died of natural causes, it also concluded that given her condition, the hospital should not have moved the woman to the retirement home.

"The circumstances surrounding this woman's death should alert health care professionals that, despite pressures to move the frail elderly out of hospitals to other settings ... it is important to remember that these elderly clients are awaiting long-term care home placement precisely because their care needs are so heavy that they are difficult, if not impossible, to provide in a community, private-care setting," the report stated.

According to provincial inspections of the Prince of Wales Manor conducted in November 2008, the facility fell short in a number of areas.

The inspection reports, obtained by the Citizen, revealed that, among other things, meals and snacks provided to "transitional care" residents did not meet the strict nutritional requirements of a provincially approved nursing home. As well, the size of the dining room and the equipment used to feed patients were not up to the provincial standards.

The inspectors found the patients' rooms didn't offer enough privacy, and washrooms weren't wheelchair-accessible. It also cited a lack of work stations for nursing staff and properly secured doors to prevent residents from wandering away.

And, according to the reports, despite having a registered nurse on staff who was on call around the clock, the Prince of Wales Manor did not have a registered nurse actually on duty 24 hours a day, seven days a week, as required under provincial regulations.

The facility did not have provincially approved care plans for each hospital patient transferred there. Absent as well was a director of care responsible for the patients' overall well-being, although the home was hiring one, the reports noted.

Officials at the Prince of Wales Manor and the Champlain LHIN were quick to point out that the inspections by health ministry officials were done voluntarily to determine what services and standards were needed to bring the "interim care" they provided to discharged hospital patients up to the same level as a nursing home.

"They were asked to come in because this was a pilot project and we wanted their feedback on what they thought about it," said Dr. Robert Cushman, chief executive of the Champlain LHIN.

"They were helping us plan to move forward," said Frank D'Amato, owner of the Prince of Wales Manor.

"I think we were aware of the standards, and our goal was to meet all the ministry standards, for sure," he said. "So we were always in a situation where we wanted to meet those standards and we were moving forward to do that. ... We were not ministry-governed at the time. It was a pilot project to see how we could manage this clientele outside of the hospital because the hospital is not an ideal situation for them. ... And the audit ... was a voluntary audit that we actually asked for."

McCallum has since recommended that hospitals assess elderly patients carefully before sending them to retirement homes, adding that those who are "functionally dependent and have significant care needs are not appropriate for placement."

Cushman acknowledged that hospitals need to do a better job screening elderly patients to determine whether they're suitable for discharge to retirement homes.

He also pointed to the need for transferred patients -- or their families -- to be able to complain about care gaps at retirement homes and be re-admitted to hospital when the transfer isn't working out. "We're going to make mistakes, but what's important is we need a feedback loop in place," said Cushman.
Maureen Taylor-Greenly, the Queensway Carleton's chief nursing executive, defended the way patients are screened.

The hospital typically consults the Champlain Community Care Access Centre, the agency responsible for home care and nursing-home admissions, to ensure that patients are appropriate for discharge, said Taylor-Greenly.

She said during the trial run, most patients referred to the Prince of Wales Manor left for nursing homes within six weeks, while "a number" of others recovered to a point where they no longer needed to wait for long-term care. "They were able to safely transition to a retirement level of living," said Taylor-Greenly.

 

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