Long-term care home death haunts daughter

A Thunder Bay woman wants to know why her mother fell out of bed — and died — just after moving into a long-term care home.

Part 2 of 'Who Cares? A CBC investigation into issues around long-term care in Thunder Bay'

Gladys Morrison died in surgery after falling out of bed at Pinewood Court long-term care home in August. Revera Homes, which runs the facility, is co-operating with a Ministry of Health investigation and conducting its own review. (Google)

A Thunder Bay woman wants to know why her mother fell out of bed — and died — just after moving into a long-term care home.

Pat Huber said there were no safety devices in place to protect her 93-year-old mother, Gladys Morrison.  

"I'm so upset with myself that I didn't ask more questions,” she said. 

In spite of health issues, Gladys Morrison, 93, was full of life right up until she died, her daughter says. (Supplied)

After Morrison fell in her own home, Huber said she thought her mother would be safer at Pinewood Court. 

"It was a really tough decision for my husband and I to put her in long-term care."

But on August 27, just two weeks after Morrison moved into the facility, she fell out of bed, broke her leg, and died in surgery the next day.  

Huber said it wasn't until she got to the hospital that she heard safety devices could have been available. She recalled the conversation with a staff person who spoke with her family in the emergency department: 

"She said ‘did your mum have a bed alarm?' I said, 'no, what's a bed alarm? [She said] 'Well, did she have a mattress on the floor, in case she did fall?’ And I said, 'no, I didn't know that was available either.' "

Long-term care homes use bed alarms and mats on the floor as safety measures for residents at risk of falling out of bed. Pat Huber says her mother, Gladys Morrison, did not have either in place when she fell out of bed last August. (Nicole Ireland/CBC)

Mats on the floor 'soften the blow'

Huber said her mother also didn't have full-length bed railings.

According to Ontario's Long-Term Care Homes Act, full bed rails can only be used with specific permission, because they're considered restraints. 

Alice Villa, the daughter of another long-term care resident, told CBC News it took a call to the Ministry of Health and Long-Term Care to learn she could request the bed railings for her elderly father.

She said despite having a bed alarm, he has fallen out of bed at least a dozen times in the year that he's been in a long-term care home. 

"It's a real safety issue," Villa said. "They've put mats on the floor to soften the blow."

A personal support worker with 15 years of experience in Thunder Bay long-term care homes, Kristine Wilson, said full-length bed railings were replaced with shorter ones so that residents would be able to move freely. 

But she said she has safety concerns about the half rails for some residents. 

"We've found people [who have] rolled out of bed ... still kind of clinging to the bed rail," she said. "It's scary."

A Toronto-based advocacy group for long-term care residents in Ontario, called Concerned Friends, said it had not heard of any safety concerns associated with the shorter railings.  

'They must know what they're doing'

Revera Living, which runs Pinewood Court, said in an email it's very sorry about Gladys Morrison's death — and that it's co-operating with a Ministry of Health investigation, as well as doing its own. 

In the meantime, Huber lives with grief and regret.

"You know, I should have looked into it more,” she said.

“I should have looked into it more and tried to figure out ... why those [safety measures] weren't in place.  Instead of going, 'well, you know, they're the professionals in this field, they must know what they're doing.'"

Full response from Revera Living, on behalf of Pinewood Court in Thunder Bay:

"We are very sorry this tragic incident occurred and our deepest sympathies are with the family. We did report this as a critical incident to the Ministry of Health and Long Term Care and are fully cooperating with its investigation as well as conducting our own review.

We can’t speak to the details of a specific resident; new residents admitted to long term care are assessed within 24 hours, building on the admission application from the CCAC. That initial assessment is followed by a 21-day period during which the individualized Plan of Care is established, which may include risk management strategies such as bed alarms or rails, if clinically indicated and agreed to by the resident.

The people who provide long term care do very special work with compassion and devotion, and nothing is more important to us than the care and safety of our residents.  We can always do better, and have a strong commitment to continuous learning and improvement."


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