the Homes Division Inspections Branch Division des foyers de soins de longue durée Inspection de Ottawa Service Area Office 347 Preston St Suite 420 OTTAWA ON K1S 3J4 Telephone: (613) 569-5602 Facsimile: (613) 569-9670 Bureau régional de services d Ottawa 347 rue Preston bureau 420 OTTAWA ON K1S 3J4 Téléphone: (613) 569-5602 Télécopieur: (613) 569-9670 Public Copy/Copie du public Report Date(s) / Date(s) du apport Jan 11, 2018 Inspection No / No de l inspection 2017_584161_0024 Log # / No de registre 016780-17, 025192-17, 026756-17 Type of Inspection / Genre d inspection Complaint Licensee/Titulaire de permis The Royale Development GP Corporation as general partner of The Royale Development LP 302 Town Centre Blvd Suite 300 MARKHAM ON L3R 0E8 Home/Foyer de Madonna Care Community 1541 St Joseph Blvd Orleans ON K1C 7L3 Name of Inspector(s)/Nom de l inspecteur ou des inspecteurs KATHLEEN SMID (161) Inspection Summary/Résumé de l inspection Page 1 of/de 10
the The purpose of this inspection was to conduct a Complaint inspection. This inspection was conducted on the following date(s): December 4, 5, 6, 7, 8, 2017. This complaint inspection is related to (1) a critical incident report that the home submitted related to an allegation of resident to resident sexual abuse and (2) one complaint related to the critical incident of an allegation of resident to resident sexual abuse and (3) one complaint related to an allegation of staff to resident physical abuse. During the course of the inspection, Inspector #161 reviewed the identified residents health care records, photographs of resident #001 and salient correspondence between the Substitute Decision Maker of resident #001 and the Assistant Director of Care, Director of Care and the Executive Director of the home. Inspector #161 also reviewed the homes policy titled Prevention of Abuse and Neglect of a Resident Vll-G-10.00 last revised January 2015 and policy titled Resident Assessments Vll-C-10.70 last revised January 2015. During the course of the inspection, the inspector(s) spoke with identified residents, the Substitute Decision Maker (SDM) of resident #001, Personal Support Workers (PSW), RAI-Coordinator, Registered Nurses, Assistant Director of Care (ADOC), Director of Care (DOC), Director of Resident Programs, Clinical Care Partner and the Executive DIrector. The following Inspection Protocols were used during this inspection: Prevention of Abuse, Neglect and Retaliation Responsive Behaviours During the course of this inspection, Non-Compliances were issued. 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s) Page 2 of/de 10
the Legend NON-COMPLIANCE / NON - RESPECT DES EXIGENCES Legendé WN Written Notification VPC Voluntary Plan of Correction DR Director Referral CO Compliance Order WAO Work and Activity Order WN Avis écrit VPC Plan de redressement volontaire DR Aiguillage au directeur CO Ordre de conformité WAO Ordres : travaux et activités Non-compliance with requirements under the (LTCHA) was found. (a requirement under the LTCHA includes the requirements contained in the items listed in the definition of "requirement under this Act" in subsection 2(1) of the LTCHA). Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue durée (LFSLD) a été constaté. (une exigence de la loi comprend les exigences qui font partie des éléments énumérés dans la définition de «exigence prévue par la présente loi», au paragraphe 2(1) de la LFSLD. The following constitutes written notification of non-compliance under paragraph 1 of section 152 of the LTCHA. Ce qui suit constitue un avis écrit de nonrespect aux termes du paragraphe 1 de l article 152 de la LFSLD. WN #1: The Licensee has failed to comply with LTCHA, 2007 S.O. 2007, c.8, s. 6. Plan of care Specifically failed to comply with the following: s. 6. (5) The licensee shall ensure that the resident, the resident s substitute decision-maker, if any, and any other persons designated by the resident or substitute decision-maker are given an opportunity to participate fully in the development and implementation of the resident s plan of care. 2007, c. 8, s. 6 (5). Findings/Faits saillants : Page 3 of/de 10
the The licensee has failed to ensure that the SDM of resident #001 was given an opportunity to participate fully in the development and implementation of resident #001 s plan of care. On an identified date in December 2017 the SDM of resident #001 informed the MOHLTC of on-going concerns related to the lack of effective strategies in resident #001 s plan of care to keep resident #001 apart from resident #002. Despite the SDM s repeated requests to keep resident #001 and resident #002 apart and monitored, the home had not considered nor included these strategies in the plan of care for resident #001. On an identified date in June 2017 Resident #001 had been physically threatened by resident #002 and between an identified date in March 2017 and October 2017, photographs were taken of resident #001 by resident #002 in the main lobby of the home without the consent of resident #001. These photographs were perceived by the SDM to be of a sexually suggestive nature. The residents were not kept apart nor monitored contrary to the repeated requests by the SDM of resident #001. On an identified date in December 2017 Inspector #161 reviewed the health care record of resident #001. On an identified date in June 2017 the progress notes of resident #001 indicated that in the main lobby on the first floor, resident #002 shook his/her fist at resident #001, grabbed the resident s forearm and made resident #001 cry. The substitute decision maker SDM of resident #001 was notified and directed the staff to keep resident #001 and resident #002 apart. On a subsequent identified date in June 2017 the progress notes of resident #001 indicated that the DOC spoke to the SDM of resident #001 to discuss the staff s perceived negative effects of keeping resident #001 and resident #002 apart and to reestablish a friendship between the two residents. The DOC indicated to the SDM of resident #001 that the home would do their very best at monitoring, to which the SDM agreed. On an identified date in early July 2017, the SDM of resident #001 sent an email to the home s DOC and ED and referenced their telephone discussion the previous week. The SDM reiterated her concerns regarding the behaviours of resident #002 towards resident #001. The SDM described in this email that resident #001 was afraid of resident #002 and requested that the distance between the two residents be maintained. The SDM reiterated the need for monitoring of resident #001 if resident #002 was in the vicinity. Page 4 of/de 10
the On an identified date in October 2017 the ED of the home submitted a Critical Incident Report (CIR) to the Director reporting alleged resident to resident sexual abuse. A review of the CIR indicated that on an identified date in October 2017 the SDM of resident #001 accidently discovered at least 18 photographs, perceived to be of a sexually suggestive nature, of resident #001, on the IPad device used by resident #002. These date-stamped photographs of resident #001 had been taken by resident #002 between identified dates in March 2017 and October 2017. On an identified date in October 2017, the ED and the SDM of resident #001 met to discuss the issue as indicated above. The decision was made to keep resident #001 and resident #002 apart and there would be monitoring to ensure same. This information was recorded in the personal notes taken by the ED as well as progress notes on an identified date in October 2017 contained in resident #001 s health care record. On December 6, 2017 an interview was held with the DOC and the ADOC who indicated to Inspector #161, that there was a document titled Guidelines for Interaction between resident #001 and resident #002 for an identified date in August 2016 that was currently posted on the bulletin boards located at the nursing stations, on the two resident care areas where resident #001 and resident #002 resided. The DOC and ADOC indicated to Inspector #161 that the purpose of these guidelines was to provide additional direction to the staff regarding the interactions between resident #001 and resident #002. The previous day, Inspector #161 had observed a document titled Guidelines for Interaction between resident #001 and resident #002 for an identified date in August 2016, in the resident s health care record. On December 6, 2017 Inspector #161 asked for and received from the DOC the document that the DOC referred to titled Guidelines for Interaction between resident #001 and resident #002 for an identified date in August 2016 described above. Inspector #161 reviewed the guidelines and noted that the second sentence stated All staff are encouraged to ensure consistency of messaging and support of resident #001 and resident #001 of their friendship. This document included such guidance as (1) they are permitted to enjoy a friendship with each other (2) they are only permitted to be together in the Main Lobby on the first floor and (3) permitted touch includes hand holding, touching arm or knee. At the time that the DOC provided the document to Inspector #161, she indicated to the Inspector that after their discussion held earlier in the day, she had removed the documents from the nursing stations as described above. Page 5 of/de 10
the On December 8, 2017 Inspector #161 met with the SDM of resident #001. The SDM indicated to Inspector #161 that she had multiple discussions with the management of the home over the past year regarding the necessity to keep resident #001 and resident #002 apart and monitored as required. Inspector #161 informed the SDM of the Guidelines for Interaction between resident #001 and resident #002 for an identified date in August 2016 as described above. The SDM indicated to Inspector #161 that she was unaware of these guidelines and furthermore, they were in direct contrast to the longstanding directions of the SDM. Inspector #161 reviewed resident #001 s care plan that was in effect on an identified date in October 2017 as well as the resident s related Kardex. There were no strategies reflecting the concerns of the SDM s in the resident s care plan nor in the resident s Kardex, to indicate that resident #001 was not to have any interactions with resident #002 and required monitoring to ensure that resident #001 was kept apart from resident #002. The licensee has failed to ensure that the SDM of resident #001 was given an opportunity to participate fully in the development and implementation of resident #001 s plan of care. [s. 6. (5)] Additional Required Actions: VPC - pursuant to the, S.O. 2007, c.8, s.152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the SDM of resident #001 is given the opportunity to participate fully in the development and implementation of resident #001's plan of care, to be implemented voluntarily. WN #2: The Licensee has failed to comply with LTCHA, 2007 S.O. 2007, c.8, s. 19. Duty to protect Page 6 of/de 10
the Specifically failed to comply with the following: s. 19. (1) Every licensee of a long-term care home shall protect residents from abuse by anyone and shall ensure that residents are not neglected by the licensee or staff. 2007, c. 8, s. 19 (1). Findings/Faits saillants : The licensee has failed to ensure that resident #001 was protected from sexual abuse in the home. According to Ontario Regulation 79/10, sexual abuse means: any non-consensual touching, behaviour or remarks of a sexual nature or sexual exploitation directed towards a resident. As a result of Resident Quality Inspection # 2017_582548_0019 that began on September 25, 2017 and concluded on October 11, 2017, the licensee was served with a compliance order pursuant to LTCHA, 2007 S.O. 2007, c.8, s. 19.(1). The compliance order was served on November 20, 2017 and was specifically related to protection of residents from sexual abuse in the home. At the time of this inspection, the compliance order served on November 20, 2017 had not reached its due date of February 19, 2018. The following non-compliance is issued related to the failure of the licensee to ensure that resident #001 was protected from sexual abuse between an identified date in March 2017 and October 2017 by resident #002, and is additional information in support of the compliance order served on November 20, 2017. On an identified date in October 2017 the ED of the home submitted a Critical Incident Report (CIR) to the Director reporting alleged resident to resident sexual abuse. A review of the CIR indicated that on an identified date in October 2017 the SDM of resident #001 accidentally discovered at least 18 photographs, perceived by the SDM of a sexually suggestive nature, of resident #001, on the IPad device used by resident #002. These date-stamped photographs of resident #001 had been taken by resident #002 between identified dates in March 2017 and October 2017. On an identified date in December 2017 the SDM of resident #001 informed the MOHLTC of concerns regarding the sexual abuse of resident #001 by resident #002 and felt that the home was not protecting resident #001 from resident #002 despite the Page 7 of/de 10
the SDM s repeated requests to do so. On December 5, 2017 Inspector #161 reviewed the health care record of resident #001. Resident #001 was admitted to the home on an identified date in 2014 with multiple medical diagnoses which included impaired cognition. Resident #002 was admitted to the home on an identified date in 2007 with multiple medical diagnoses which included impaired cognition. On the evening of an identified date in October 2017, resident #002 approached the SDM of resident #001 and asked for assistance in downloading a game onto the IPad that resident #002 was using. While doing so, the SDM of resident #001 observed photographs of resident #001, perceived by the SDM of a sexually suggestive nature, taken in the main lobby of the home as well as photographs of resident #001 s clothes, including pajamas and undergarments, prominently displayed on the bed of resident #002. On an identified date in October 2017, the ED of the home received a voice mail from the SDM of resident #001 regarding her discovery on an identified date in October 2017, of the photographs. These photographs had been taken by resident #002 over an eight month period in 2017; the photographs were date stamped between March 2017 and October 2017. On an identified date in October 2017, both the ED and Charge Nurse #108 interviewed resident #001 regarding the photographs taken by resident #002. Resident #001 indicated to the ED and Charge Nurse #108, that she/he had felt pressured by resident #002 to pose for the photographs and felt that if she/he had refused to have the photographs taken, resident #002 would have become angry at her/him and would not want to be resident #001 s friend. On December 5, 2017 Inspector #161 discussed the above-described incidents during an interview with resident #001. The resident indicated to Inspector #161 that she/he had not agreed to the photographs taken by resident #002 on the identified dates between March 2017 and October 2017. Resident #001 further indicated to Inspector #161 that she/he felt very uncomfortable and pressured by resident #002 into having the photographs of her/him taken and felt that she/he didn t have a choice. Resident #001 stated resident #002 thinks he/she is the boss (of me). The resident thinks it is ok to touch me because he/she is the boss. I didn t want to. Page 8 of/de 10
the Over the course of this inspection, Inspector #161 discussed the above noted photographs involving resident #001 and resident #002 with the ADOC, DOC and ED. They indicated to Inspector #161 that there had been a past episodic history between resident #001 and resident #002 of a sexual nature and aggression that necessitated that both residents be supervised whenever they were together in the main lobby on the first floor of the home. The ADOC, DOC and ED further indicated to Inspector #161 that they were unaware of the photographs taken by resident #002 of resident #001 until the SDM of resident #001 brought this information to their attention on an identified date in October 2017. On December 6, 2017 the ADOC and DOC indicated to Inspector #161 during an interview, that they had not put a formal process in place to supervise resident #001 and resident #002 when the two residents were together in the main lobby on the first floor of the home. The ADOC and DOC assumed that with the traffic flow of people in the main lobby of the home including visitors and staff members, that resident #001 and resident #002 would not have engaged in any sexual behaviours. On December 6, 2017 an interview was held with the ADOC, DOC and the Clinical Care Partner staff member regarding the process and criteria for the assessment of residents to determine (1) a resident s capacity to provide consent to a person s touching, behaviour or remarks of a sexual nature and (2) if the resident consented to the touching, behaviour or remarks of a sexual nature. At the time of the inspection, the ADOC, DOC and the Clinical Care Partner staff member indicated to Inspector #161 that there was no policy nor procedure in place that would provide management or staff with guidance or direction related to the process of determining a resident s capacity to consent to engage in an interaction of a sexual nature. In addition to the above findings and in further support of non-compliance identified under section 19 of the LTCHA 2007, the license has failed to comply with: i. LTCHA 2007, c.8, s.6(5) The licensee shall ensure that the resident s substitute decision maker, is given an opportunity to participate fully in the development and implementation of a resident s plan of care. (Refer to WN #1) [s. 19. (1)] Page 9 of/de 10
the Issued on this 12th day of January, 2018 Signature of Inspector(s)/Signature de l inspecteur ou des inspecteurs Original report signed by the inspector. Page 10 of/de 10