Alberta Health. Protection for Persons in Care. Decision Summaries Q2, Communities M Z

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1 Alberta Health Protection for Persons in Care Decision Summaries Q2, Communities M Z Important: Please read this notice Protection for Persons in Care (PPC) conducts investigations in response to reports of abuse under the Protection for Persons in Care Act. PPC does not conduct inspections or investigate all complaints that may arise in a particular facility or in relation to a particular service provider. Therefore, this report may not contain all information relating to inspections or other complaints in regards to a particular service provider. This report includes a link to the Health Quality Council of Alberta (HQCA) Supportive Living Resident, Family or Long-Term Care Family Experience Survey Report. The following is a summary of the allegations of abuse that have been the subject of a decision by the Director of PPC as to whether an allegation of abuse was founded or not founded ( Decision Summaries ). The Decision Summaries may contain any steps and measures issued by the Director. Please note the Decision Summaries are provided for informational purposes only and represent findings in regards to allegations of abuse, as identified to PPC at a particular point in time and in relation to a particular service provider and a specific incident(s). The Decision Summaries should not be relied upon to form conclusions about the current or future quality of care offered by the identified service providers. The absence of any Decision Summaries evidencing allegations of abuse relating to a particular service provider should not be accepted as a conclusion that a higher level of care can be expected from that service provider. For details on the legislation, please see the Protection for Persons in Care Act Summary. For routine inspection reports on continuing care accommodation standards, please visit the Accommodation Standards and Licensing public reporting site. For resident and family experience survey results, including Global Overall Care ratings for participating sites, please see the survey reports for supportive living and long-term care facilities on the Health Quality Council of Alberta (HQCA) website. Supportive Living Resident Experience Survey Report ( ) Supportive Living Family Experience Survey Report ( ) Long-Term Care Family Experience Survey Report ( ) For an explanation of terms and abbreviations, please see the PPC Decisions User Guide Government of Alberta 1

2 Table of Contents Note: Click on the name of the service provider/facility to directly access its decision summaries. Mannville... 3 Continuing Care (includes long-term care and supportive living)... 3 Mannville Care Centre... 3 Medicine Hat... 5 Continuing Care (includes long-term care and supportive living)... 5 Valley View Continuing Care Centre... 5 Onoway... 8 Seniors' Lodges... 8 Chateau Lac Ste. Anne... 8 Red Deer Persons with Developmental Disabilities Programs...10 Michener Services Sherwood Park Persons with Developmental Disabilities Programs...13 Robin Hood Learning Centre Strathmore Persons with Developmental Disabilities Programs...14 Calgary Progressive Lifestyles Foundation Government of Alberta 2

3 Mannville Continuing Care (includes long-term care and supportive living) Mannville Care Centre Street Mannville, AB T0B 2W0 Type of Facility: Long-term care Capacity: 22 Operator: Government Funding: Alberta Health Services Alberta Health For facility ratings, please see the Health Quality Council of Alberta (HQCA): Resident Rating: Supportive Living Resident Experience Survey Report Family Rating: Supportive Living Family Experience Survey Report Long-Term Care Rating: Long-Term Care Family Experience Survey Report ( ) Number of Founded Allegations: 1 Number of Allegations: 0 Individual Involved: Type of Abuse: Service Provider The individual involved failed to assess and monitor the client's medical condition. The client was transported to hospital where the client was observed to have severe discoloration to their mouth and extremities. The client was diagnosed with an infection. Failure to Provide Necessities of Life: services from a service provider that results in failing to provide adequate nutrition, adequate medical attention or another necessity of life without a valid consent, resulting in serious bodily harm. Founded 2017 Government of Alberta 3

4 1) That facility management work with Alberta Health Services (AHS) clinical nurse specialists or educators to provide education to applicable staff about best practices for prevention, recognition and treatment of urinary tract infections, most particularly in the presence of indwelling catheters. 2) Utilize best practice standards to create a policy/procedure/guideline for the management of diabetes. Include relevant definitions; blood glucose monitoring and documentation; monitoring food intake; treatment of hypoglycemia and hyperglycemia; the procedure for blood glucose testing; insulin types and action; staff roles and responsibilities; when to contact a physician; and blood glucose meter quality assurance checks. Educate staff about the policy/procedure/guidelines. 3) Create or update the facility policy/procedure regarding assessment of client s who have a significant change in their medical status. Include the roles and responsibilities of staff regarding monitoring, assessing, reporting and documenting when a client has a change in their level of consciousness. Educate staff about the policy. 4) Create a policy/procedure or update the existing facility policy/procedure to address the frequency with which clients who have long-term indwelling urinary catheters be assessed. Include which comprehensive assessments should be completed, who should complete the assessments and when to contact a physician. Provide education to staff about the policy/procedure. 5) Utilize best practice standards to implement a quality improvement program to reduce the risk of catheter associated urinary tract infections. Regularly assess clients with catheters for the appropriate use of the catheter; criteria for the removal of catheters that are no longer needed; and alternatives to urinary catheters. 6) Consider creating a process where clients have their incontinence product checked frequently throughout the day and night Government of Alberta 4

5 Medicine Hat Continuing Care (includes long-term care and supportive living) Valley View Continuing Care Centre 65 Valley View Drive SW Medicine Hat, AB T1A 7K5 Type of Facility: Supportive living Capacity: 56 Operator: Government Funding: AgeCare Investments Ltd. Alberta Health For facility ratings, please see the Health Quality Council of Alberta (HQCA): Resident Rating: Supportive Living Resident Experience Survey Report Family Rating: Supportive Living Family Experience Survey Report Long-Term Care Rating: Long-Term Care Family Experience Survey Report ( ) Number of Founded Allegations: 0 Number of Allegations: 5 Individual Involved: Type of Abuse: Type of Abuse: Service Provider The individual involved repeatedly transferred the client manually, in a rough manner, instead of using a mechanical lift. The manual transfers caused the client pain. Bodily: services from a service provider that causes serious bodily harm. Emotional: 2017 Government of Alberta 5

6 1) Provide education to all Health Care Aids (HCA) staff about all facility policies, procedures, and standards of care related to client care plans, the use of mechanical lifts and speaking to clients about their care. 2) Complete an internal review to determine if the misuse of mechanical lifts is a systemic issue within the facility. 3) Provide education to all staff about client dignity and the procedure for providing a bed bath. 4) Provide education to all staff about the prevention of skin tears. 5) Change the orientation questionnaire answer for question number five to reflect that staff is to call 911 if they think a person or client is in imminent danger; if they believe a client has been abused staff should call the Protection for Persons in Care (PPC) reporting line number Individual Involved: Service Provider The individual involved roughly removed the client s clothing causing the client pain and emotional upset. Type of Abuse: Bodily: services from a service provider that causes serious bodily harm. 1) The directive issued was specific to an individual and is not included to protect personal 2) The directive issued was specific to an individual and is not included to protect personal 3) The directive issued was specific to an individual and is not included to protect personal Individual Involved: Type of Abuse: Service Provider The individual involved put the client in bed without using a mechanical lift, removed the client s clothing, and then squeezed body wash down the client s bare chest without telling the client what was being done. Emotional: 2017 Government of Alberta 6

7 1) The directive issued was specific to an individual and is not included to protect personal 2) The directive issued was specific to an individual and is not included to protect personal 3) The directive issued was specific to an individual and is not included to protect personal Government of Alberta 7

8 Onoway Seniors' Lodges Chateau Lac Ste. Anne Avenue Onoway, AB T0E 1V0 Type of Facility: Capacity: 92 Seniors' lodge Operator: Government Funding: Lac Ste. Anne Foundation Alberta Seniors For facility ratings, please see the Health Quality Council of Alberta (HQCA): Resident Rating: Supportive Living Resident Experience Survey Report Family Rating: Supportive Living Family Experience Survey Report Long-Term Care Rating: Long-Term Care Family Experience Survey Report ( ) Number of Founded Allegations: (April 2017 March 2018) 0 Number of Allegations: (April 2017 March 2018) 2 Individual Involved: Type of Abuse: Service Provider The individual involved failed to assess and monitor the client who was having difficulty breathing. The client was transported to hospital and was diagnosed with pneumonia. Failure to Provide Necessities of Life: services from a service provider that results in failing to provide adequate nutrition, adequate medical attention or another necessity of life without a valid consent, resulting in serious bodily harm. Review the intake process and the terms of the occupancy agreement to assess that the information provided at the time of intake related to what services are and are not provided is clear to clients and their families. If necessary, revise the process and/or agreement so this information is clear. Compliance Status: Yes Date of Compliance: July 26, Government of Alberta 8

9 Individual Involved: Type of Abuse: Service Provider The individual involved told the client that the facility was not an appropriate place for them to live and that should the client be admitted to hospital again they would not be accepted back to the facility. This caused the client to become visibly upset. Emotional: 1) Review the intake process and the terms of the occupancy agreement to assess that the information provided at the time of intake related to what services are and are not provided is clear to clients and their families. If necessary, revise the process and/or agreement so this information is clear. 2) Review and where applicable, revise the client reassessment process, to include increased timeliness, transparency, and a copasetic approach regarding possible transitions to alleviate clients fears. 3) Arrange that conversations with clients and families related to increased client care needs are conducted in the presence of an impartial second party. Compliance Status: Yes Date of Compliance: July 26, Government of Alberta 9

10 Red Deer Persons with Developmental Disabilities Programs Michener Services 12 Michener Road East 2 Red Deer, AB T4P 0J9 Program Located in: Red Deer Type of Facility: Persons with Developmental Disabilities programs Operator: Government Funding: Central Region Community Board Human Services Number of Founded Allegations: 0 Number of Allegations: 5 Individual Involved: Service Provider The individual involved restricted the client from leaving the residence, continually badgered the client and would not give the client space or time to calm down. The client cried and used profanity toward the individual involved who also administered the client s medication unnecessarily. 1. The directive issued was specific to an individual and is not included to protect personal 2. If not already covered in a yearly update, add review of support plans to the scheduled topics for review Individual Involved: Type of Abuse: Service Provider The individual involved continually badgered the client. The client became upset and screamed several times at the individual involved to stop. Emotional: 2017 Government of Alberta 10

11 1. The directive issued was specific to an individual and is not included to protect personal 2. The directive issued was specific to an individual and is not included to protect personal 8642 Individual Involved: Service Provider The individual involved continually badgered a co-client. The client became upset and was shaking. 1. The directive issued was specific to an individual and is not included to protect personal 2. The directive issued was specific to an individual and is not included to protect personal 8643 Individual Involved: Another Client The individual involved hit the client in the upper part of the body. The directive issued was specific to an individual and is not included to protect personal Compliance Status: Yes Date of Compliance: July 26, Government of Alberta 11

12 Individual Involved: Another Client The individual involved hit the client with an open hand. Since the incident, the client has been heard muttering and pointing at the individual involved when in sight. The directive issued was specific to an individual and is not included to protect personal Compliance Status: Yes Date of Compliance: July 26, Individual Involved: Another Client The individual involved bit the client, removing some of the client s flesh. The client was transported to hospital for assessment and treatment. Type of Abuse: Bodily : services from a service provider that causes serious bodily harm. Founded 1. The directive issued was specific to an individual and is not included to protect personal 2. The directive issued was specific to an individual and is not included to protect personal 3. The directive issued was specific to an individual and is not included to protect personal Government of Alberta 12

13 Sherwood Park Persons with Developmental Disabilities Programs Robin Hood Learning Centre 141 Broadway Boulevard Sherwood Park, AB T8H 2A4 Program Located in: Sherwood Park Type of Facility: Persons with Developmental Disabilities programs Operator: Government Funding: Robin Hood Association for the Handicapped Human Services Number of Founded Allegations: 0 Number of Allegations: 1 Individual Involved: Another Client The individual involved verbally threatened the client with physical harm. The client is fearful of the individual involved. Not Applicable Compliance Status: Not Applicable Date of Compliance: Not Applicable Government of Alberta 13

14 Strathmore Persons with Developmental Disabilities Programs Calgary Progressive Lifestyles Foundation 140, Avenue NE Calgary, AB T2E 7C8 Program Located in: Strathmore Type of Facility: Persons with Developmental Disabilities programs Operator: Government Funding: Calgary Progressive Lifestyles Foundation Human Services Number of Founded Allegations: (April 2017 March 2018) 0 Number of Allegations: (April 2017 March 2018) 2 Individual Involved: Service Provider The individual involved constantly yelled at and berated the client. The individual involved made the client ask to use the bathroom but would sometimes deny the request so the client would urinate/defecate outdoors. The client was isolated from social contact and is extremely afraid of the individual involved. 1) The directive issued was specific to an individual and is not included to protect personal 2) The directive issued was specific to an individual and is not included to protect personal 3) The directive issued was specific to an individual and is not included to protect personal 4) That all staff responsible for completion of an internal investigation following the receipt of an allegation of abuse review the Persons with Development Disabilities Abuse Prevention and Response Protocols and the service provider s abuse policy. 5) That the service provider add contractors to the Reporting of Abuse Allegations policy, the Recruitment and Selection policy, and the Employee Mandatory Minimum Requirements for Employment. 6) That the service provider revise policies and adjust supervision schedules for any clients who live in isolated situations so that isolated clients receive more than one visit per month and that clients have the opportunity to meet with their case manager alone Government of Alberta 14

15 Individual Involved: Service Provider The individual involved constantly yelled at and berated the client. The individual involved made the client ask to use the bathroom but would sometimes deny the request so the client would urinate/defecate outdoors. The client was isolated from social contact and is extremely afraid of the individual involved. 1) The directive issued was specific to an individual and is not included to protect personal 2) The directive issued was specific to an individual and is not included to protect personal 3) That all staff responsible for completion of an internal investigation following the receipt of an allegation of abuse review the Persons with Development Disabilities Abuse Prevention and Response Protocols and the service provider s abuse policy. 4) That the service provider add contractors to the Reporting of Abuse Allegations policy, the Recruitment and Selection policy, and the Employee Mandatory Minimum Requirements for Employment. 5) That the service provider revise policies and adjust supervision schedules for any clients who live in isolated situations so that isolated clients receive more than one visit per month; that clients have the opportunity to meet with their case manager without the supportive roommate being present; and that clients have the opportunity to attend a full time day program off site with a support worker different than the supportive roommate Government of Alberta 15