Ombudsman identifies series of problems before, after woman’s death in long-term care

It was just over a week between when Rose Botting’s mother, Frances Sander, was admitted to a long-term care home in Rosetown and when she died in hospital.

According to a report from the provincial ombudsman, which was finished in August, Sander was admitted April 4, 2018 and was immediately assessed as having a high risk for falls, so there was a care plan developed.

That plan was strengthened after Sander had a fall that night.

But six days later, Sander was found on the floor in the bathroom, bloody and unable to speak except to moan. She was moved to a hospital where she eventually lapsed into unconsciousness. She died three days later.

“We were absolutely shocked and stunned,” Botting said Tuesday.  “Her face and head were covered in bruises and we were just like, ‘What happened here?’ My sister and I both thought, ‘Did someone beat her up? How did this happen?’ ”

Botting said no investigation was started into what happened to her mother until she and her sister pushed for it.

“Which was completely inappropriate. If you’re working in a hospital or nursing home and you … find someone on the floor bleeding and unconscious that is in the bathroom, that is a critical incident, there’s no question,” said Botting.

She and her sister are also the ones who went to the ombudsman to have the office look into her mother’s death as well.

The ombudsman found that, while there was a care plan in place for Sander, it wasn’t followed.

The report showed figuring out how often the staff checked on Sander was difficult. At best she was left alone for several hours when staff were supposed to check on her at least every two hours and, Botting thought, every hour.

The ombudsman found that Sander could have been on the floor of the bathroom, hurt and bleeding, for an hour and 45 minutes before she was found.

“We find that the Authority’s failure to perform intentional rounding and scheduled toileting as required by Frances’ care plan may have significantly contributed to her falling and injuring herself,” read the report.

The report also found Sander’s bed alarm wasn’t properly used because none of the staff could say whether it was properly turned on or functioning properly. When questions arose, they were brushed off, saying sometimes they don’t work anyway.

“In our view, these reports and responses show that Rose Villa’s management and staff had what appears to be a disturbingly cavalier approach to ensuring Frances had a functioning bed alarm while she was in bed,” read the report.

Because of these things, the ombudsman found the Saskatchewan Health Authority failed to provide a minimum standard of care for Sander.

Even after the fall, the ombudsman found things didn’t go properly within the home. The ombudsman had issues with how the incident was reported, saying it was misleading. Also the incident wasn’t properly reported and should have been deemed a critical incident quickly instead of only after a meeting with family.

After the incident was deemed critical, the report found it took too long to finish the investigation and report – something that was at least contributed to by the fact the investigator was inexperienced and not thorough, was investigating it along with their other duties, and was uncomfortable with having to investigate their co-workers.

“The Authority’s failure to report, classify, investigate and report on this as a critical incident in a timely manner as required by the Act and the Regulations significantly contributed to the family’s dissatisfaction with the outcome of the review and their continued pursuit for answers,” read the report.

The ombudsman noted in the report that Sander’s situation isn’t the first time the office has investigated a death caused by a fall in long-term care, and it isn’t the first time it has found an event should have been deemed critical and investigated earlier than it was. It also wasn’t the first time the office found the person tasked with investigating the incident had adverse duties and had to investigate co-workers.

The ombudsman made two recommendations:

1. “The Saskatchewan Health Authority develop and implement a single, comprehensive, province-wide, adverse health event reporting and investigation process that clearly identifies the notification, reporting and investigative requirements and processes for all special-care homes and other facilities operated by the Authority.

2. “The Saskatchewan Health Authority ensures anyone assigned to investigate an adverse health event, including critical incidents, is: (a) sufficiently independent so that a reasonably informed person would not be concerned about their impartiality; and (b) appropriately trained to carry out investigations professionally, comprehensively, and in a timely manner.”

The report noted the health authority agreed with the recommendations and had already taken steps to achieve them. The health authority did not respond to a request for comment Tuesday.

The ombudsman’s report was finished in August — more than three years after Sander’s death and two years after the investigation began — but it wasn’t released publicly.

Leila Dueck, communications director for the ombudsman’s office, said most reports are not released publicly but often are just summarized in the annual report.

Botting said her family wanted to release it and wanted to bring what happened to light.

“We feel that the public needs to know that seniors may not be safe in their nursing homes,” said Botting. “And we also want to put the government’s feet to the fire (and) the Saskatchewan Health Authority’s feet to the fire about making sure seniors are safe in our funded facilities.”

When it comes to the recommendations, Botting talked about a lack of teeth.

“What power do they have?” she asked. “What teeth do they have? If the government chooses to ignore it (and) the Saskatchewan Health Authority chooses to ignore it like they apparently have in other ombudsman reports and the ombudsman says they’re going to be checking, and then if they check and nothing’s done, then what happens?”

Botting was at the legislature at the invitation of the NDP. Seniors Critic Matt Love said Sander’s story shows the need for fully funded and legislated minimum standards for care.

“The care that Frances received is below any minimum standard that could possibly exist,” said Love. “I think that we all need to consider what we would want for our own loved ones in a similar situation.”

Love said short-staffing in long-term care is a long-standing problem in Saskatchewan, though in this case it’s unclear what role that might have played.

After Question period, Seniors Minister Everett Hindley said he appreciated Botting coming and sharing her story, and said he would be meeting with her later in the afternoon.

Hindley said as for the recommendations in the ombudsman’s report, work is well underway to implementing them, and he expects that will be done as quickly as possible.

“This is an area that we’re focused on in terms of continuous improvement, so there’s a number of areas we need to improve on. (As for the) recommendations from whether it’s the auditor or the ombudsman’s office, those are being implemented,” said Hindley.

The minister said the government wants to learn from incidents like this and minimize the chance of them happening again.