Seniors' advocate cites nursing home, provincial failures in senior's death
Resident in 90s repeatedly assaulted by another resident, family told he fell
George was an avid curler, a great-grandfather and remained active into his 90s. But, Alzheimer's disease led to his family deciding he needed to be in a nursing home to stay safe.
It was in that home that he was repeatedly assaulted by another resident and hospitalized with a broken hip. After two weeks in hospital, George died. The assault led the coroner to rule his death was a homicide.
The care provided by the nursing home and a subsequent investigation by Social Development's Adult Protection unit are the subject of a 38-page report released Thursday by New Brunswick Seniors' Advocate Norm Bossé.
"What we found was a wide array of failings ranging from the nursing home's inability to protect residents from harm and under-reporting of major incidents, to an Adult Protection investigation that did not take measures to ensure that all relevant and pertinent information was obtained and reviewed," the report says of the advocate's probe that began in February 2021.
Family not given full picture
The report paints a picture of a series of steps to minimize incidents, a family kept in the dark, and a man illegally discharged from the nursing home out of fear for what his family might do.
George's family was only told he had fallen, later learning the truth from surveillance video.
The report intentionally omits the name and location of the nursing home, dates and the actual names of the people involved to protect people's privacy.
The man's children told the advocate in interviews that they had moved their father into the nursing home to keep him safe after trying to keep him at home.
The report says that if the nursing home disclosed what was happening, they would have considered hiring a sitter or re-arranging their schedules to spend more time visiting their father.
One of George's daughters "will carry with her forever a paralyzing feeling of guilt," the report says.
Two patients, three assaults
Two weeks before George moved into the unnamed nursing home, another man with dementia named Tom was admitted. The report describes Tom acting violently toward other residents, one woman in a wheelchair he shoved into a wall and later punched in the face.
It was during Tom's third week in the home that a licensed practical nurse on a night shift found George on the floor with Tom standing nearby.
"He pushed me to the ground," George said, according to the report. It was described to George's family as a fall. The incident wasn't reported because it was "an unwitnessed fall."
The following month, George was sent to hospital to get stitches on his elbow from another "fall."
The report says no effective safeguards were put in place to prevent further violence. Employees interviewed for the report said they realized George was not safe in Tom's presence, but felt their concerns and suggestions to management "fell on deaf ears."
A third "fall" happened less than a week later, requiring hospitalization for a broken hip.
The report says George appeared to have become scared in the home, with staff finding him sitting in a corner and on guard in case of another attack. George's family was told by hospital staff he would cower in their presence and plead with them not to hurt him.
His family questioned the falls as prior to admission he was "able-bodied and walking independently."
They insisted on watching surveillance video of the last two incidents, only then learning of Tom's assaults that caused George to fall. Footage of the first incident wasn't saved. The video left them "shocked and traumatized," the report states.
George's death was deemed a homicide by the coroner, which means it was a death caused by another person. The determination doesn't mean his death was criminal. No criminal investigation occurred.
Social Development's Adult Protection investigation review noted that Tom's dementia diagnosis meant there wasn't a way to determine if there was intent in his actions, a key factor in whether actions are criminal.
'Superficial' provincial investigation
The advocate's report found a myriad of problems with the Adult Protection investigation, calling it "inadequate" and "superficial."
The investigation didn't include interviews with staff who work directly with patients. Records of staffing levels reviewed to determine if the home was adequately staffed during an assault was for the wrong day.
The social worker who carried out the investigation was aware of Tom's assaults against other residents, but limited their probe to the incident with George, the report says.
"Given the limited focus of the Adult Protection investigation, the lack of comprehensive interviewing of relevant people, and the lack of due diligence in documentary examination, we must conclude that the Adult Protection investigation was inadequate in the determination of level of risk to all of the nursing home's residents," the report says.
The discharge was illegal. It was also uncaring.- Seniors' Advocate report
The nursing home, three days before George's death, discharged him in violation of Nursing Home Services Standards. Nursing home staff told the Adult Protection social worker they believed that his family would blame the nursing home if George died.
The report says a letter from the home to his daughter about the discharge "claimed that her accusatory actions were disrespectful and that her father's continued stay at the nursing home 'unduly endangers the safety of himself, other residents and staff.'"
"The discharge was illegal. It was also uncaring," the report states.
Employees of the home told the seniors' advocate nursing home management were instructed not to attend George's funeral or contact his family. That, the report says, was a surprise as many of them had regularly attended residents' funerals.
The family confirmed the information, though management of the home "disputed these claims entirely," the report states.
The report views the claims as true.
Speaking about the discharge in an interview Thursday, Bossé said there were signs the home was concerned about the family going public or getting sued.
"That's never a good reason," Bossé said. "That absolutely is the worst thing you could ever have done."
He hopes publishing the report will lead to changes.
"The situation depicted in this report is troubling and it's not something we're taking lightly," Bruce Fitch, the province's minister of Social Development, told reporters Thursday. He said the province will review the report and its recommendations and make any changes required.
The minister said the situation doesn't reflect a systemic issue with New Brunswick's long-term care homes.
Michael Keating, interim executive director of the New Brunswick Association of Nursing Homes Inc., also called the report "troubling."
The group representing non-profit nursing homes is willing to work with the province to make changes, he said. The association doesn't represent the home George lived in, Keating said.
"Much of what I read with respect to recommendations are not things I would oppose," Keating said.
The report makes 13 recommendations, including:
- Social Development to develop best practices for violence mitigation;
- Improve reporting requirements for violent incidents;
- Publicly report findings from inspections that find homes with persistent non-compliance with the law and standards;
- Create a standardized complaint process;
- Improve training for staff on violence reduction and mandatory reporting to the department that the training has been completed;
- Improve investigations by Adult Protection, including by interviewing residents, staff and family members;
- Ensure prior to a nursing home resident's discharge that the department and seniors' advocate is notified and for an assessment of the discharge to take place.
With files from Harry Forestell