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Protection Of Persons In Care Investigation Report, CEDA-2023-10
After months of a grueling and problematic investigation process my complaint regarding my mother Margaret Macomber's terrible experience at Shannex's Cedarstone was determined to be founded. The consequences for my mother's unmanaged, new, extreme pain and injury over a period of days? Shannex / Cedarstone received directives, listed below, telling them to follow their existing policy. I began to research and found that it's a much bigger problem than I'd realized. Please join me in looking for answers. Here are the directives from Margaret's investigation:
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.
Referrals
In addition to directives, Protection of Persons in Care can refer to professional bodies. The Act indicates:
Referral by Minister to professional body
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(1) Where the Minister believes on reasonable grounds that a person has abused a patient or resident or has failed to comply with the duty to report
under Section 5, the Minister may refer the matter to the body or person that governs the person’s professional status or that certifies, licenses or otherwise authorizes or permits the person to carry on the person’s work, profession or occupation.
(1A) The Minister’s referral under subsection (1) shall include a
written summary of the matter being investigated.
(2) A body or person that receives a referral under subsection (1)
shall
(a) investigate the matter to determine whether a professional status review or disciplinary proceedings should be commenced against the person; and
(b) on conclusion of the investigation and any review or
proceedings, advise the Minister of the determination under clause
(a), the reasons for the determination, and, where applicable, the
results of any professional status review or disciplinary proceedings.
(3) Where a referral is made under this Section to a body or person that the Minister considers can deal appropriately with the matter, the Minister
may decide not to appoint an investigator under Section 8, or may defer doing so.
2004, c. 33, s. 12; 2013, c. 26, s. 5.
Protection of Persons In Care won't tell me if they referred Margaret's investigation to the Nova Scotia College of Nurses. I can't find any record on the Nova Scotia College of Nurses website where they have sanctioned a nurse doing patient care in long term care. They are required to post sanctions. There may be some and I will continue to look.
Fines
Protection of Persons in Care can fine individuals and corporations who contravene the Act. Here is what the Act states:
Offences, penalties and limitation
17
(1) A person who contravenes this Act is guilty of an offence and
is liable on summary conviction to
(a) in the case of an individual, a fine of not more than two
thousand dollars; and
(b) in the case of a corporation, a fine of not more than
thirty thousand dollars.
I'm waiting for a FOIPOP response to see how often or if they use fines. Here is an excerpt from a May, 2019 article in Saltwire:
Robert Lafferty, the Health Department’s director of investigations and licensing compliance, has told The Chronicle Herald fines are not the only tool to force a home to make changes.
“Typically what happens is we work with homes to bring them into compliance,” said Lafferty. “If it ever got to a point that we were so concerned about a facility that we were going to fine them, they would basically lose their license. That’s the approach we would take.”
Licensing and Inspection
I wonder what it would take for a long term care facility to have their license suspended or revoked? How would that work, given the care requirements of the residents? I'll find out since the director of investigations and licensing indicated in 2019 that losing their license was the approach they'd use before a fine.
You can find Nova Scotia Long Term Care Licensing and Inspection Reports here. Shannex's Cedarstone, where Margaret was staying, had sixty three requirements from licensing inspections from July, 2019 to October, 2023. Some are very similar to the directives they received as a result of my complaint and some are repetitive. For example from July, 2023:
LTCPR 6.2.8 The licensee shall ensure residents' health status is monitored daily and there is a system in place to recognize indicators of residents' changing needs and to respond accordingly.
Here is a random selection of some of the other licensing requirements Cedarstone received:
HSCR 18(3)
In every nursing home and nursing care section of a home for the aged where
there are thirty or more residents, there shall be at least one registered nurse
on duty at all times.
LTCPR 11.1.11
Additional Requirements for Nursing Homes - The licensee shall ensure the
home is staffed in accordance with the staffing model as funded by the
Department of Health and Wellness.
HSCR 27(11), LTCPR 9.2.4.g
No person shall be maintained in a home for special care or any part thereof that
is not approved by a Fire Marshal with respect to fire safety.
LTCPR 6.4.1
The licensee shall ensure resident-centred care, which recognizes the value of
providing a safe, homelike environment with an emphasis on meeting the
physical, health, cultural, spiritual, social, mental and emotional needs of
residents, is provided for all residents.
LTCPR 7.1.12
The licensee shall ensure required inspections of the home and equipment are
completed and documentation is maintained to demonstrate compliance with
requirements. These include, but are not limited to, manufacturer requirements,
safety requirements, sprinkler systems, water testing, fire alarms and fuel
systems.
LTCPR 6.6.3
The licensee shall ensure each resident has a daily mouth care plan that
includes appropriate hygiene techniques and products to maintain oral
cleanliness of natural teeth and/or dentures.
HSCR 27(8), LTCPR 9.2.4.d, LTCPR 9.2.4.e
The licensee shall ensure fire protection equipment is maintained in good
working order. Fire alarms and fire doors are tested monthly; fire extinguishers
are inspected monthly and tested annually in accordance with the Office of the
Fire Marshal. Records of testing and inspections of fire protection equipment
and systems are maintained.
Would you have confidence and trust that directives were going to trigger change and protect residents?
A final note - there are many, many good nurses, care workers, doctors, service providers and facilities in long term care. I'm completely supportive of nurses being paid competitive salaries and staffing levels to counter burn out.
Thank you for reading my blog. I'm happy to make corrections if any are found.
