Posts Tagged Nursing home

Where does the Rot Start in Nursing Home Abuse?

This story has been bouncing around the Canadian media since last May. Camille Parent, the son of a nursing home resident, set up a hidden camera in his mother’s room for four days after she (the nursing home claimed) was assaulted by another patient. The results were appalling. Watch here:

The nursing home immediately fired the four staff members seen in the video; the contract of the director was not renewed. The police, however, have decided not to prosecute; the legal case for pressing assault charges, they said, is a lot narrower than what you or me would consider abusive.

That the standards in this nursing home are so abysmally lax is nearly beyond comprehension. Just after this particular facility opened about ten years ago, I accompanied a friend on a tour of the place. I remember thinking at the time, “If I ever need supportive care, this is where I want to go.” They had an exemplary care model, good staff/patient ratios, and a well-designed environment.

For me, it was interesting the reflex reaction of the director was to axe the employees involved, because as we all know, the best way to address issues in any health care institution is to fire employees.

Voilà! Problem fixed!

The problem with this hypothesis (i.e. the Rogue Employee Theory) is that four employees in four days with one patient displayed behaviours that were, um, sub-optimal.

No, sorry. You can’t just blame the employees, though they need to be accountable for their actions. The administration of the nursing home needs to take some (most?) of the responsibility for permitting an institutional culture where waving faeces-soiled wash cloths in patients’ faces, and canoodling in patients’ rooms is acceptable behaviour.

Let’s take a look at the Mission and Values statement of the nursing home:

Our Mission

St. Joseph’s at Fleming is a non-profit long term care health provider committed to excellence in the delivery of quality care and services to persons of all faiths. Continuing the legacy of the Sisters of St. Joseph of Peterborough, the Home takes pride in a model of care distinguished by compassion, dignity, respect and integrity.

Our Vision

Leader and valued partner in long term care through the use of innovation and best practices in living, learning and caring.

Our Core Values

St. Joseph’s at Fleming is committed to creating a healthy living and working environment that:
[. . . ]

• Treats people with fairness and social justice

[. . . ]

St. Joseph’s at Fleming is committed to creating a unique learning environment for Residents, families, staff, volunteers and students that:

• Promotes innovation and best practices

[. . . ]

• Develops leadership and promotes teamwork

St. Joseph’s at Fleming is committed to providing exemplary physical, emotional and spiritual care to our Residents, their families, staff and volunteers. Our philosophy of care:

• Engenders trust, healing and wholeness 
• Integrates best practices and innovative solutions
• Promotes individuality as well as personal and spiritual growth 
• Is characterized by compassion, respect, dignity and the sanctity of life

All of which is very good, anodyne and even commonplace, and I am sure it looks very nice hanging in the front lobby. It’s pretty easy to point out where the nursing home and its employees betrayed its own mission and values, so obviously, it’s not enough. If I were the provincial investigator looking at this nursing home, my very first question would be, “How are your values exemplified in how you provide care?” In other words, how do you ensure institutional values — all those warm fuzzies listed above — align with the personal values of the staff? (Clearly, they didn’t in this case.) And also: what policies and procedures do you have in place that address abuse? What education do you give staff around patient abuse, or the issues that surround the care of cognitively impaired patients?  How do you evaluate the effectiveness of that education? How do those in leadership positions role model behaviour? What processes do you have in place to care for demented patients? How do front line staff participate in the development of such processes? How do you reward/celebrate excellence? And so on.

I’m guessing the answers to most of such questions would be “a little” or “not at all.”

So who should be held accountable?

The front line staff?


The leaders, the managers and the administrators?

Yes. Probably more so.

So what do you think? Who is to blame? Staff or administration or both?

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Insert Snark Here

English: Linear Skull Fracture with arrow poin...

What this patient did not have

Mr. CD, 88, took a little tumble at the nursing home when he slipped on a loose rug (or something, the details are a little vague here), obtained for his trouble a scalp laceration the length of Q-tip on his temple, bled like a stuck pig, transported by EMS, triaged, assessed by both MD and RN, x-rayed, CT’d, declared medically cleared and fit to go home, deblooded, stapled, tetanus’d, acquired a head dressing worthy of a maharajah, and finally sent back to the nursing via a private ambulance and their ill-paid yet (hopefully) competent attendants.

Whereupon the RPN (i.e. LPN for you out of province types) or whoever was minding the door of the nursing home refused to take the patient back.

“Oh my God, he needs to go back the emerg,” she said, eyeing, perhaps, the overwrought head bandage. “He has a skull fracture! I can tell!” And promptly sent him back, alert, oriented x 3 — and bemused.

I have only two possible explanations for her extraordinary statement: she either is wasting her time at the nursing home and depriving humanity of a set of assessment skill so exquisite she can, using her psychic x-ray powers, detect a skull fracture under approximately twenty layers of clean, white 4 x 4 sponges and tape gauze, or else she thinks despite all the assessments and investigations, we are complete boobs. ( Admittedly, I have a sneaking sympathy at times for the second possibility.)

There is actually a third possibility, but I am far too polite to mention it.

That’s all I got. Feel free to insert your own snark.

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So When Does This Become a Crisis?

I walked into the Emergency Department one hot morning a couple of weeks ago and found every last stretcher — twenty-five beds, including the two we try to reserve for trauma or codes — was filled with admitted patients; furthermore, five additional patients were waiting for consultants and likely admission. We were operating at 120% capacity even before the usual gamut of ED patients would begin flooding in.

Trying to manage an ED under these circumstances is like walking through an open field holding an umbrella during a thunderstorm. You know lightning is going to strike, and you hope like hell it doesn’t strike you. As charge nurse you start re-triaging the patients already under your management. Which admitted patients requiring cardiac monitoring can be safely parked in the hallway (in violation of fire codes) to make room for the syncopal vag bleed at triage? Which chest pain gets the last monitored bed? Is that MVC the paramedics rolling in nothing or a multisystem trauma?

And then, nurses providing care at the front-line begin to get frustrated and angry, because all of them chose to be ED nurses (as opposed to med-surg nurses), and they have lots of expensive education to validate their choice. In the event, they are helpless watching their elderly admits decompensating before their eyes.

Even more seriously, the sudden arrival of a trauma or a patient coding in the waiting room means a scramble to find room; in a scenario when seconds count, delay could be disastrous if there is no available bed to treat them. I don’t actually think the general public understands the fine line emergency department nurses and physicians walk between successful outcomes, where the patient is treated, made well, and discharged, and the morgue. Every health care professional in the ED practices with their heart in their throat and their licences over the fire.

So when does this become a crisis?

We’re told the principal cause of ED overcrowding is patients waiting for long-term care blocking acute-care beds. Not quite coincidentally the Toronto Star recently published an article about the appalling treatment an elderly woman received at the hands of a nursing home called Upper Canada Lodge in Niagara-on-the-Lake. The woman, named Sylvia Bailey, had a broken tibia which was left by nursing home staff untreated for twenty-three days.* She later died because of complications related to the fracture, and the case is now subject to a coroner’s inquest.

The two issues are not unrelated. Health care for seniors is vastly underfunded, and it’s reflected in both the number and quality of beds available. As a society we tend to give a lot of lip service to the care and support we give to seniors. In reality the frail elderly are at the bottom of the health care food chain. They aren’t glamorous or fashionable or have carefully managed public-relations campaigns associated with them. How many people do you see wearing a bracelet or ribbon for proper health care for seniors?

I tend to be quite cynical about this. The elephant in the room is that care for seniors is expensive, and no politician seems to be willing to state the obvious: provision of even adequate supports for a growing population of senior citizens is going to take a considerable mobilization of financial resources, i.e. increased taxes. Politicians love adopting seniors as a apple-pie issue. But given the current political climate which informs us we’re over-taxed, nurses are over-paid,and  the health car system is bloated, and throw in dodgy financial calculations by every provincial political party, any politician who tells you the case of Sylvia Bailey shall never be repeated, and ED wait times will magically disappear is flat-out lying.

So again, when do we decide this is a crisis?


*College of Nurses of Ontario, are you listening?

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How Mr. Jones Died

Mr. Jones was 83-years-old when he died. He came to us by ambulance from with shortness of breath beginning a little after lunch. He was from a nursing home; he had the alphabet soup of morbidities: CHF, CVA, NIDDM, CAD, COPD  — topped off by dementia related Parkinson’s.

He had pancreatic cancer, and plainly, he was dying. His advanced directives, outlining the plan for end-of-life care stated no heroic measures, but if he became seriously ill, he was to be transported to the emergency department for evaluation.

The nursing home where he lived did just that. He went through the usual emergency department process — seen, treatment started and referred to the internist for admission — all the while obtunded and gasping for air, despite the high flow oxygen. He  was a tall man, broad-shouldered; he lay restless in the narrow emergency department stretcher, his gnarled feet hanging over the end.

A flood of patients had deluged the hospital. There were no beds upstairs. I talked with Bed Flow and we made Mr. Jones a priority for a bed. But somehow his criteria never met bed availability, and when I came back two days later, he was still in the Observation room — and still no room on the floors. I had Housekeeping look for a regular hospital bed for him. There were already three being used in the department, and the overflow of  admitted patients meant there were none to spare. The Obs room nurses provided comfort measures, did mouth care, applied barrier cream over bony prominences, repositioned every two hours. They did what they could, but in truth, they were not palliative care nurses, a unique speciality unto itself. He never opened his eyes and he died by inches. Mr. Jones finally went three days after admission. His feet were still hanging over the end as we packed him away in the body bag and sent him to the morgue.

For the nurses, who knew what care Mr. Jones deserved, the experience was distressing. For the family, it was devastating, a layer of suffering over grief. For the patient himself, we can only hope he knew little and felt less.

There is absolutely no space in the system for patients like Mr. Jones — elderly, debilitated and often requiring complex amounts of care — to die with dignity. Nursing homes, despite their demographics, are very poorly equipped and frankly don’t have the resources to deal with dying patients. They dislike having dying patients; they will send them to the emergency department even when the advanced directives explicitly state the patient is not to be transported. Emergency departments are similarly not geared for end-of-life care, even though death is something we deal with frequently. We have neither equipment nor expertise; we don’t even have ready access to expertise.

And yet the case of Mr. Jones is not exceptional. How can we ensure people can die comfortably and with dignity? It’s a problem, I think, without at quick fix, but is by no means intractable or even complicated. It means explicitly recognizing that for the majority of cases, the best place to die is not in hospital, but at home or under nursing care in the community, and providing the resources to make it possible. And if such patients must come to ED, giving us the tools to do our jobs properly, so we can provide safe, competent and ethical care. That would be a good start, and a necessary one.

Because all I can think, that might be me one day. Or you.

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How Nursing Homes Fail: The Perspective of Family

I asked Jenn Jilks, a long time reader and commenter here, to write a few words on nursing homes, and the sometimes disgraceful care they provide for residents. The problem isn’t that nursing home operators “try hard”, or “do the best they can with limited resources”; the real issue is the lack of accountability inherent in the system, whether its unlicenced and unregulated care providers, the lack of stringent provincial standards for nursing home care, or the larger questions of a government which believes the minimal standards are good enough, or of  taxpayer subsidies to a profitable industry.

Jenn maintains and writes several blogs: Cottage Country Reflections, Thank Your Teachers and Ontario health Care — For Those Over 50.

My mother died at home and my father died in a long-term care (LTC) facility. I became heavily involved, as I wanted to have some influence. As things progressed I did a bit more research. Having been a caregiver in Mom’s home, I saw both sides of the coin. I have many issues with for-profit LTC.

  • In Ontario, over 500 of the 600 LTC institutions are FOR-PROFIT.
  • Food in LTC is appalling.
  • Most of the care in LTC is provided by unregulated, non-professionals with a gr. 12 degree. Some have a training certificate.
  • The disparities between rural and urban care continues.
  • The highly-touted Aging at Home Project did not create many jobs, and failed to find more staff for under-staffed institutions.

I met a lot of people in these homes. Calling the patients residents is a bit disingenuous. Those with strokes, or comatose, spend their days horizontal. Many I met were unable to make their way around their homes any more. Some were tired. With incredible life stories, now wheelchair bound, they spend their days waiting by the dining room in preparation for the next meal. Many use the retherm method, simply reheating food you cannot recognize as food.  Spareribs with no bones and veggies with no life. If you’ve ever fed pureed food to a frail senior, you will know how difficult this is. What I wouldn’t have given to see my father eat an apple or a banana.

In the meantime dividends are sent to shareholders of the for-profits.

Now, these places have intense programs, with activity directors who set up many activities. There are volunteers who spend time feeding, fundraising, or entertaining those in the residence. For the most part, the homes I visited in Muskoka were places where a harried crew of people worked hard to ensure that these people, who are loved by someone, can spend their days clean, busy, well-fed and engaged. Many are in pain, however, and lonely.

Personal support workers (PSWs) are involved in the intimate care of these people who cannot care for themselves.  Some call them Health Care Personnel (HCPs), to my mind they are interchangeable, but not all are equal. Caregivers can range from the very competent, to those incapable of finding a kind word for a resident and barely literate. They are running, most of the time, trying to find another staffer to move a resident from bed to wheelchair or toileting. Some work for private agencies, some work for profit agencies, called in to LTC or retirement homes to supplement staff. There are huge inconsistencies. Who dares complain?

With only a minimum grade 12 education, a short number of months at a college, PSWs find themselves wiping the most intimate of areas, and doing things for our elders that was formerly done by themselves independently and alone. Some try to diagnose for resident’s families. The college certificate required by some for-profit institutions is inconsistently provided. None are followed long-term by the nursing departments who supervise them. Especially in the north, where workers are in high demand, the poor ones quit and go private. In the meantime, we spend big bucks advertising to promote an awareness of elder abuse.

We cannot call them nursing homes much anymore, as much of the ‘nursing’ is done by non-professionals. I’m not talking about medications, or more complex care. Most of the time there is a Charge Nurse on the floor. She spends time handing out meds or sorting out treatment plans and the paperwork that engulfs all professionals. There are never enough PSWs to do the lifting, transfers, changing of incontinence products or feeding required. As for physicians.  .  . they are few and far between. It took me two months to get adequate pain meds for Dad. No one recognized his signs of pain: singing, fussing with clothes, agitation, and it is my endless regret that I did not fight harder.

In my experience poverty leads to institutionalization, rather than disabling diseases. Many seniors would rather die in filth, alone, than suffer the embarrassment of giving up their independence of their own homes. The government does not pay enough to truly support our elders. Nursing homes are staffed according to the number of residents, not the severity of their illnesses, those with chronic disorders and/or mental illnesses cannot get the individual care they merit. Our tax dollars go to subsidize the residency of the old and frail in LTC who cannot support themselves in their homes due to failing health, failing eyesight, or failing bank accounts. The shame of it is we do it so poorly.

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A Bad Death

A few days ago a 70ish-year-old patient arrived by EMS, end-stage liver cancer, sent in by her family because she was “not feeling well”. From home. No advance directives. She was frail and obviously unwell, jaundiced, her abdomen distended by ascites. EMS reported she was vomiting blood on the way in; her pulse was racing, her blood pressure was dropping. I asked her the paramedics to offload her into a Resus Room bed, and I followed in to help EMS lift the patient into the emerg stretcher and to help the primary nurse with the assessment.

The patient looked me in the eye, a look, I think,  of astonishment, vomited once, and coded. We did the usual: called the code, started chest compressions (and fracturing ribs in the process), started IVs (the paramedic were unable to get a line), pushed drugs, until the family arrived and the physician went out to speak to them. There was a lot of blood. She was PEA; she had likely bled out from some complication of cancer. A pump needs fluid to work. A few minutes later the physician returned and pronounced death.

It was a bad death. I’ve seen several deaths like this in my years in the emergency department, concerned family sending in people at the verge of death or nursing homes calling EMS for residents at the end of life (at the behest of families or physicians responsible) who end by dying within minutes or hours of arrival. Some of them have elaborate direction for the end of life (but are ignored by well-meaning, or to be less charitable, indifferent family members); others, like this patient, seemed to have no sort of plan at all, despite being considered terminally ill.

I get that families sometimes cannot cope at home with desperately ill family members, or they live in a state of denial, or that they sometimes panic at the end of life; staffing issues in nursing homes make it difficult to carry out end-of-life directives, or institutional hospice care is often limited, or sometimes people near the end of life are unclear about the options available to them, that dying at home, comfortable in familiar surroundings is feasible and even desirable. But the alternative, dying on an emergency department stretcher with cracked ribs and all manner of other pointless physical indignities inflicted, seems grotesque, demeaning and otherwise an unworthy way to end a life.

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Some Days You Just Gotta Post Links

Sorry. No new content today. Just links. Sore brain.

  • Unions step up fight against pay freeze: “Women who care for the elderly in publicly funded nursing homes in Toronto make, on average, 2.5 per cent of the compensation paid to CEOs like Tim Lukenda at Extendicare,” Stewart said. “Mr. Lukenda made $1.5 million including bonuses last year. Is the CEO really worth 50 times more than the woman providing care?”
  • Some preemie babies ‘give up’ to blunt repeated pain: “Premature babies are repeatedly exposed to painful invasive procedures, yet only 36 per cent of premature babies in Canada get pain relief, according to Celeste Johnston, a McGill University nursing professor and expert in neonatal pain.”

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