Medication errors, understaffing plagued homes where serial killer nurse worked, inquiry hears

Provincial long-term care inspectors found problems with how medication was stored, administered and disposed of at a London, Ont., nursing home where serial killer Elizabeth Wettlaufer worked, an inquiry heard Friday.

Other inspectors found a Paris, Ont., home where Wettlaufer also worked repeatedly violated provincial law that dictates minimum staffing levels at nursing homes. 

The two homes, Meadow Park in London and Telfer Place in Paris, came under scrutiny at the long-term care inquiry Friday. 

Provincial investigators were sent into the homes after Wettlaufer confessed to killing eight patients in her care and trying to kill or harm six others. One of her murder victims lived at Meadow Park and one of people she tried to kill lived at Telfer Place. 

Telfer Place is a small home, with just 45 beds, testified health ministry inspector Lisa Vink.

Still, it must, like all long-term care facilities in the province, regardless of size, have one practical nurse who is employed by the home on shift 24/7.

Telfer Place, owned by Revera, one of North America's largest providers of long-term care services, violated that rule 25 times over a period of several months by having a temp agency nurse oversee the home.

On seven occasions, a registered practical nurse did that work. 

"There were occasions when, due to a variety of reasons, they were just not able to have a registered nurse on the floor," Vink said. But those occasions didn't meet the definition of an "emergency" that would exempt the home from meeting its obligations. 

Telfer Place also didn't properly train staff and didn't ensure that temp agency nurses had proper background checks, Vink found. 

Wettlaufer was not well liked at Telfer Place and after making several crude remarks to co-workers and having an odd interaction with a doctor who didn't feel she was competent, the home asked the temp agency, Lifeguard Home Care, to stop sending her there. 

The temp agency began sending her to home-care clients. 

Policies 'not well understood'

When she went into Meadow Park two days after finding out Wettlaufer had confessed to killing resident Arpad Horvath, 75, Ministry of Health and Long-Term Care inspector Natalie Moroney said she found a host of medication-related problems. 

Wettlaufer had also confessed to killing seven people while working at the Caressant Care nursing home in Woodstock from 2007 to 2014. 

Moroney was the lead investigator at Meadow Park, where Wettlaufer worked for five months in 2015. 

The provincial inspections resulting from Wettlaufer's confession to serial murder lasted from October 2016 to March 2017. 

"We were just there for one day and there were concerns," Moroney said. "The policies and procedures were not well understood."

In a medication cart, Moroney found loose opioids that weren't marked to say who they belonged to or when they were supposed to be given, and medication in Dixie cups that weren't in their original packaging. 

"In the medication room there was a large bin for disposal, the containers were full, there were ampules in there, and needles, medication that should have been [destroyed], and there should have been a lid on those bins and there was no lid," Moroney testified at the Elgin County courthouse in St. Thomas where the long-term care inquiry has been taking place for weeks. 

Moroney also found critical incidents that happened while Wettlaufer worked at the home and that were not reported to the ministry, including one where Horvath had been found tightly tied to his bed rail with the tie from his jogging pants, one where a resident was sexually touched by a visitor to the home and another in which a resident was pushed by another resident. 

In another incident, also not reported to the ministry, a patient was screaming in the night and was unable to sleep. That resident was in distress but didn't get any intervention, and there was no pain assessment conducted, Moroney said. 

'You deserve to die without suffering'

Moroney said there's nothing the ministry could have done to prevent Wettlaufer's crimes. 

"As an inspector in the home, there was nothing that suggested that Elizabeth Wettlaufer was giving lethal doses of insulin to Arpad Horvath. Families were not aware, co-workers were not aware," she said. 

"Long-term care for most people is their very last home. They're leaving home, they're leaving their partner who they've had all their lives, and they're entrusting that home to give care and dignity. You deserve to die without suffering and without pain." 

Moroney said she believes the nursing profession has been tainted by Wettlaufer. 

"I love being a nurse. I've always loved being a nurse. Nurses are caring and compassionate and empathetic. They're the advocate, they're truthful, and that's what nursing is all about. It's about giving care and giving dignity."