Mom and I This is my mother Margaret Macomber's final investigation report regarding her abuse at Shannex's Cedarstone Enhanced Care in Truro, Nova Scotia. It was prepared by Protection of Persons in Care, a division of the provincial Seniors and Long Term Care department. Some points are misleading, i.e. despite my clarification it states that I was indecisive about my mother going to hospital when in fact the Cedarstone staff told me they would get help more quickly and the hospital would be many hours, so I followed their advice still believing they wanted to help. (I've since learned in reading reports of abuse in Shannex facilities that other families have been discouraged from taking their loved one to hospital in cases of abuse. Perhaps it's related to the fact that the hospital reported the abuse in mom's case to Protection of Persons In Care.)
While my opinion / percepton is that the investigation and report were somewhat biased in Shannex's favour, it does shed light on the incident and confirm that abuse occurred. If there are other people who are willing to share their experience with Protectionn of Persons in Care I would love to hear your stories, good or bad. Did you make a complaint that wasn't investigated? It was investigated but abuse was determined unfounded despite evidence to the contrary? It was investigated and you're satisfied with the outcome regarding the findings and consequences? Please contact me at carol@fivefires.ca, subject line Abuse, if you have knowledge to share confidentially or publicly.
The thing about this incident that haunts me is that many of the same facilities, for profit corporate chain facilities, are repeatedly documented as abusing helpless seniors while facing no consequences. You read that right. They are profiting but are not required to pay the fines provided in law or criminally prosecuted. Ever. Some individual nursing homes belonging to the corporate chains have as many as twelve confirmed abuses from March 2017 to March 2024.
Please forgive the formatting. It's converted from a pdf so difficult to manage.
THE REPORT:
May 7, 2024 carol@fivefires.ca
Carol Macomber
SDM for Margaret Macomber
Dear C Macomber:
Re: Final
Investigation Report - File #: CEDA-2023-10
On September 21, 2024, a report was made
under the Protection for Persons in Care
Act (PPCA) as outlined in the Final Investigation Report.
After a full investigation, the PPCA Office has concluded that the
reported allegation is founded.
A copy of the final report is enclosed for
your review.
If directives have been issued to the administrator of the
health facility, the administrator is required to submit an action plan to
address the directives If no directives were issued to the administrator, this
file will be closed.
Staci Corbett, RD
Investigation and Compliance Officer
Department of Seniors and Long Term Care
OVERVIEW:
•
On September 21, 2023, a report was received under the Protection for Persons in Care Act
alleging failure to provide adequate nutrition, care, medical attention or
necessities of life without valid consent as defined in section 3(1) (g) of the
Regulations.
•
It was alleged that the affected resident did not
receive adequate medical attention during a period of severe pain and
discomfort.
•
It was determined that there were reasonable grounds to
conduct an investigation pursuant to section 8 (2) of the Protection for Persons in Care Act.
•
The investigation included interviews with relevant
parties. The resident’s chart, care plan, Medication Administration Records
(MARs), and other related documents were reviewed as part of the investigation.
SUMMARY OF INFORMATION
COLLECTED:
1.
It was reported that on September 16, 2023, the
affected resident began showing signs of discomfort, displayed by shouting for
help, moaning and rubbing their chest.
2.
A progress note dated September 16, 2023 at 22:21h
states:
“Resident was unsettled
the whole night, keeps on shouting for help but relieves for a while when sipping water.
Cannot stay still on bed (keeps on moving- risk for fall) and rubs their chest
when shouting for help. Ensured safety, endorsed.”
3.
Upon review of the affected residents Medication
Administration Record (MAR) for September 16, 2023, the affected resident was
given regularly scheduled acetaminophen at 1635h and 1942h.
4.
Staff # 1 reported that they had come onto the unit for
the first time on September 16, 2023, and were not familiar with the affected
resident. Staff # 1 reported that care staff reported the affected resident’s
behaviour as abnormal but as the affected resident would settle with sips of
water, they continued with comfort care.
5.
Staff # 1 reported that they did obtain a set of vitals
for the affected resident and informed a responsibility nurse of the affected
resident’s behaviour on the evening of September 16, 2023; however, there is no
documentation to support this.
6.
Staff # 2 reported that when they came on day shift on
September 17, 2023, it was their first day shift since the affected resident
was admitted to the facility on September 1, 2023. Staff # 2 reported that the
affected resident was not eating well that day, which was reportedly not
abnormal. Staff # 2 reported they informed a supervisor that the affected
resident just wanted to stay in bed and was not wanting to consume food or
supplements.
7.
Staff # 2 reported that they asked the affected
resident if they were in pain, to which the affected resident replied “no”, and
that they just wanted to stay in bed.
8.
A progress note in the affected resident’s chart on
September 17, 2023 at 1733h states:
“Throughout the weekend resident has not been eating well- maybe 25% of
meal consumed, refused to eat and would holler if was brought to the dining
room for mealtime and request to be taken back to their room... Meal tray was
provided in the room but with the same outcome only consuming 10% of resource
ordered and not finishing. Talked to (staff) and was decided to send urine
sample for assessment to the laboratory Monday (tomorrow), will endorse.”
9.
Staff # 2 reported that they took the affected
resident’s temperature and recalled it being in the normal range; however,
there is no documentation to support this.
10.
Staff # 3 reported coming onto day shift on September
18, 2023, and being told in report that the affected resident was in pain from
the night before. Staff # 3 reported that the affected resident was moaning in
pain but was not able to pinpoint where the pain was located.
11.
It was reported that when the affected resident’s
Substitute Decision Maker (SDM) came in to visit on September 18, 2023, at
approximately 1030h that the affected resident was “screaming in pain, guttural
screams”, and that they pressed the call bell to alert staff. It was reported
that when staff came to the affected resident’s room, the SDM asked them to
help the affected resident and was told that the pain started last night and
that they would have to call the doctor to get an order for additional pain medication.
The SDM reported that they were not contacted by the facility to be alerted of
the affected residents change in health status, from the night before.
12.
A progress note in the affected residents chart from
September 18, 2023 at 0800h states
“Around 8 in the morning, resident was out in the dining room for
breakfast. Writer noted resident was restless and agitated while on (their)
chair and was shouting. Writer tried to offer porridge but resident refused.
Resident was asked if they has any pain but doesn’t respond. V/S taken of
166/91, P: 86, R:26, T:36, O2 sat 97%. Writer tried to give their morning pills
but resident refuse. Resident was assisted back to their room and was put to
bed and did rested well. Around 1030, SDM came in and resident was starting to
get restless again telling (their) SDM (they are) in pain. PRN Tylenol was
given with a brief relief. Writer asked the SDM if she wanted to transfer to
hospital and said yes but then took it back and just wants to give comfort
measures and requested injectable medications for pain. Writer and RN
(initials) tried to call (doctor) multiple times to get an order for morphine
but couldn’t get a hold of (doctor). Writer and RN (initials) faxed Dr.
regarding residents condition. SDM was frustrated on why we couldn’t get the
doctor right away and verbalized “ this is inhumane” and “ I won’t think twice
of publicizing this situation”. A dark colored blood was seen after Tylenol
suppository was given. Resident did settle afterwards. Writer called 911 and
asked if they can give emergency morphine as we couldn’t get an order for it.
EMS came in around 1500H and assessed resident. Vital signs are within normal
limit, ECG was taken, morphine SQ was given. SDM then decided to bring resident
to the hospital. At 1530h, resident left facility for the hospital.
13.
The affected resident was transferred to hospital at
approximately 1530h on September 18, 2023.
14.
A triage assessment from September 18, 2023, was
observed from the emergency department as part of the investigation and stated
the following:
“1630h- 99f w/
abdominal/chest pain since yesterday. Was yelling and moaning in pain on
arrival but has received 5mg morphine sq and quite comfortable now.”
15.
A history and physical document, from the receiving
hospital, was reviewed as part of the investigation and stated the following:
“Reason for Admission-
probable acute MI
General- Affected resident was distressed with pain on presentation.
The morning after admission, they are sleeping deeply with pain medications
having been given.
Plan- this 99 year old
(pronoun) seems to have had some significant event, likely cardiovascular event
with their elevated troponin. Their lactate was also elevated…”
ADDITIONAL INFORMATION
COLLECTED:
16.
Upon review of the affected resident’s Medication
Administration Record (MAR) from the facility, it was observed that Tylenol
(acetaminophen) was a regularly scheduled medication and there were no other
medications ordered for pain.
PRN (as needed)
Medication Administration Records (MARs) were requested as part of the
investigation; however, the investigator was informed that the affected
resident did not have any PRN medications prescribed.
17.
Staff # 3 reported that the affected resident’s Pathway
of Care was limited interventions / No CPR. Staff # 3 also reported that the
SDM for the affected resident was indecisive on whether or not they wanted the
affected resident transferred to hospital, or to stay at the facility and kept
comfortable.
18.
A three-day admission assessment was observed as part
of the investigation and included a section to assess pain. It was completed
for September 2, 3, 4, 2023 and indicated that the affected resident did not
complain or show evidence of pain nor had sudden, acute flare ups of pain.
19.
Staff # 4 reported that there was a delay in contacting
the facility physician as staff working were calling and faxing the physician’s
office number and not their cell phone. It was reported by staff interviewed
that they did not have any additional phone numbers or way to contact the
physician aside from the phone number to the physician’s office.
20.
It was reported that as part of the internal
investigation conducted by the facility, it was determined that the process for
contacting the facility physician was updated with direction for staff to
request a transfer to the facility physician’s cell phone in the case of an
emergency when calling the physician’s office number.
21.
It was reported by all staff interviewed that the
affected resident’s substitute decision maker (SDM) was not made aware of the
affected resident’s health status from September 16-18th, 2023,
until they arrived at 1030h on September 18, 2023.
22.
The affected resident was unable to participate in the
investigation.
ADDITIONAL
INFORMATION:
•
The Medication Administration Record (MAR) for the
affected resident was reviewed as part of the investigation. It was noted that
their regularly scheduled Tylenol was documented on the MAR as being refused by
the affected resident on September 17, 2023, at 0800h, 1200h, 1600h and 50%
taken at 2000h. Additionally, the 0800h dose of Tylenol was documented as being
refused on September 18th, 2023, as well.
•
According to the facility’s Medication Management
Policy, if the resident refuses a medication or treatment, continue to make
attempts to assist with the medication or treatment. However, if you run out of
the window of time for taking the medication or treatment (refer to medication
administration SOP) and the resident still declines, place a circle in the box,
write your initials inside this circle, and chart the reason for the refusal in
the notes on the back of the MAR or TAR.
Notify the
appropriate person of this refusal.”
•
According to the facility’s Pain Management Policy, any
change in resident condition that may be contributed by pain, must trigger a
pain assessment to be completed along with care planning for pain in
collaboration with the interdisciplinary team and the Substitute Decision Maker
(SDM). A pain assessment for the affected resident was completed on admission,
however, subsequent pain assessments were not observed as part of the
investigation.
•
It was documented in the affected resident’s progress
notes that a skin tear occurred on their left shin on September 7th,
2023. This was documented and treated and SDM notified. Additionally, on
September 10, 2023, a progress note indicated a skin laceration was observed on
the affected resident’s lower left leg and was treated according to the wound
care policy. On September 16, 2023, a progress note indicated the affected
resident had a scratch on their left backside, (2.3 inches) and purplish
bruises to both arms and legs.
•
A progress note from the affected resident’s file on
September 18, 2023 at 0455h states:
“At around 0340h CCA on
duty (initials) informed writer that resident has wound on (their) leg and it
is bleeding. Upon assessment writer noted blood on the bedsheet and on the left
side rail. Multiple skin tear was noted on the left lower limb and with light
bleeding, no swelling noted. Writer cleansed wound with NSS, painted with
betadine, Covered with non-adherent dressing and wrapped with a kling…”
RESPONSES TO
PRELIMINARY INVESTIGATION REPORT:
A response to
the Preliminary Investigation Report was not received from the facility.
A 23 page response to the Preliminary Investigation Report
submitted by the Substitute Decision Maker for the affected resident has been
reviewed and considered in the investigation. The response included questions,
comments, and points of clarification, some of which have been added above in
“Additional Information”. While not an exhaustive list, some of the relevant
responses are summarized below:
The
SDM reported that on September 18, 2023:
“I
arrived at Cedar Stone at 10:30 am and heard (affected resident) screaming as I
came through the doors to (their) wing. I got to (their) room and (their) door
was closed. Rushing to (their) bedside I grabbed the call button and rang for
help, assuming that staff didn’t know that (affected resident) was in severe
distress. When I asked staff to help (affected resident) they said that (they)
refused to take (their) acetaminophen that morning. Nothing else was offered.
(Their) ‘refusal’ to take (their) medication was the only explanation provided
for (their) condition. I, completely untrained in medicine, could see (affected
resident) wasn’t capable of taking (their) medication (they later vomited). I
asked that staff get injectable pain medication and medical attention
immediately. (Affected resident’s) legs
were badly cut when I arrived, adding to (their) pain. Staff told me (affected
resident) had cut them on the bed rails when thrashing in pain. The bed rails
were down when I arrived and (affected resident) was still thrashing.
(Affected
resident’s) pain continued with the exception of two brief respites until
approximately 3:00 pm.
Although
(they) couldn’t swallow medication, acetaminophen suppositories weren’t offered
until hours after I started begging for help. When the suppository was provided
staff noted that (affected resident) had blood in (their) rectum. Injectable
pain medication wasn’t provided until I threated to post video of (affected
resident) screaming and writhing in pain to social media. EMT’s were there
within minutes and immediately recognized that it was an emergency.”
FINDINGS:
On September 16th,
2023, it was documented that the affected resident was shouting for help and
rubbing their chest, which was reported as abnormal behaviour by care staff.
The following day, a staff member reported to their supervisor that the
affected resident was not eating well and hollering when brought out to the
dining room. It was reported that the affected resident was asked if they were
in any pain and reportedly stated “no”. It was reported that staff obtained
vitals on multiple occasions as part of their assessment of the affected
resident, however, there is no evidence to support this nor evidence to support
that the affected resident was asked if they were in pain and replied “no”.
On review of the
Medication Administration Record (MAR) it appears as though the affected
resident refused their regularly scheduled Tylenol during three medication
passes on September 17, 2023, and only took 50% of the dose at 2000h. On
September 18, 2023, it was reported that the affected resident was in pain from
the night before, moaning in pain, however, there is no documentation to
support that the affected resident was experiencing pain or any evidence of
investigation into this pain.
On September 18,
2023, the Substitute Decision Maker (SDM) reported that when they arrived at
the facility, the affected resident could be heard screaming from down the hall
and was in obvious pain in their room. The SDM reported that they were told the
pain began the night before, September 17, 2023. The SDM was not made aware of
any change in condition beginning on September 16, 2023, until they arrived at
the facility on September 18, 2023, at approximately 1030h. The facility
physician was unable to be reached via phone and fax after several attempts,
and EHS was called, at the insistence of the SDM, to administer injectable pain
medication. The admitting hospital noted that the affected resident was yelling
and moaning in pain on arrival, which is supported by the SDM’s account of the
events, however, there appears to be a discrepancy between documentation of the
affected resident’s pain from the facility and the accounts from the SDM and
admitting hospital. It was noted that the affected resident experienced a
probable acute MI after the admitting hospital’s investigation.
Although there
is a discrepancy between what was reported and documented by the SDM, admitting
hospital and the facility, it can be concluded that the affected resident began
experiencing some level of discomfort on September 16th, 2023, as
evidenced by rubbing their chest and shouting out for help, until being
transferred to hospital on September 18, 2023 at 1530h. Documentation detailing
the affected resident’s pain and discomfort was limited, pain medication
refusals were not reported to a charge staff or documented in the chart, the
affected resident’s SDM was not notified of a change in condition, or
medication refusals, until they arrived and witnessed the affected resident in
pain and discomfort. Vitals were reportedly obtained on multiple occasions,
however, there is no documentation to support this. Additionally, according to
the facility’s pain management policy, a change in condition that may be
contributed to pain, must trigger a pain assessment. A pain assessment was
completed on admission for the affected resident on September 2,3, and 4, 2023
which indicated that the affected resident did not complain or show evidence of
pain nor had sudden, acute flare ups of pain, therefore the change in behaviour
noted on September 16, 2023, should have triggered a pain assessment to be
completed. There was no evidence of a completed pain assessment after September
4, 2023.
Although there
is evidence that care staff were completing tasks related to care for the
affected resident, several staff reported that they were unfamiliar with the
affected resident, their baseline, or usual behaviours, which contributed to a
failure to recognize and act upon a change in condition and behaviour of the
affected resident beginning on September 16, 2023. There is a lack of
documentation and follow-up related to vitals, pain assessments, medication
refusals and reports to supervisors. Additionally, there was a failure to
provide timely communication to the SDM and facility physician contributing to
the affected resident experiencing pain and discomfort for several hours.
As a result of
the lack of overall coordination and oversight of care, the allegation of
failure to provide adequate nutrition, care, medical attention or necessities
of life without valid consent as defined in section 3(1) (g) of the Regulations is founded.
DIRECTIVES:
1.
During the investigation, it was reported that staff
obtained vitals on multiple occasions, however, they were not documented in the
affected resident’s chart. Additionally, descriptions of pain and health status
changes, interventions related to mitigating pain and medication refusals were
not documented and/or did not follow facility policy for documentation
standards. As such, it is required that the Administrator ensures all staff
involved in the allegation are provided with education related to the Medication
Management Policy and documentation standards for clear, timely and accurate
documentation.
2.
During the investigation interviews, it was reported
that staff relayed pertinent information to other staff members and/or
supervisors about the affected resident’s condition, however, progress notes
only indicated that information was “endorsed” with no further detail. The
Administrator shall ensure that the process for sharing report and information
with oncoming shifts and/or supervisors is reviewed, and documentation shall
reflect who the information is reported to.
3.
During the investigation, there is evidence that the
affected resident experienced a change in health status ie: pain. There was no
evidence that the Substitute Decision Maker (SDM) was notified of the change in
health status. As such, the Administrator shall ensure that relevant staff,
including facility management, review the facility’s SDM informing process, to
ensure SDMs are appropriately, and accurately, informed of all concerning
information involving residents in a timely manner, and that such communication
is documented on resident charts.
4.
According to the facility’s Pain Management Policy any
change in resident condition that may be contributed by pain, must trigger a
pain assessment to be completed along with care planning for pain in
collaboration with the interdisciplinary team and the Substitute Decision Maker
(SDM). Staff failed to recognize or act on the change in condition of the
affected resident and therefore did not complete a pain assessment. The
Administrator shall ensure that all staff involved are provided with education
on the Pain Management Policy, conducting pain assessments and recognizing
changes in resident condition.
5.
Despite individual staff documenting concerns
identified with the affected resident, there was a lack of overall coordination
of care and accountability. Staff reported being unfamiliar with the affected
resident. The Administrator shall ensure that the process for coordination of
care, including reporting, oversight and decision making is reviewed to ensure
all staff are familiar with their role in continuity of care for residents.
