Ombudsman's report slams Sask. Health Authority in death of long-term-care resident

The Saskatchewan Health Authority failed to provide a long-term care resident, who died three days after taking a fall, with the minimum standard of care required by the Ministry of Health’s program guidelines for special-care homes, the ombudsman has found.

SHA didn’t properly implement risk-of-falling care plan: report

Saskatchewan’s ombudsman has found that the province’s health authority failed to provide a long-term care resident, who died three days after taking a fall, with the minimum standard of care required by the Ministry of Health. (Trevor Bothorel/CBC)

The Saskatchewan Health Authority (SHA) failed to provide a long-term care resident, who died three days after taking a fall, with the minimum standard of care required by the Ministry of Health's program guidelines for special-care homes, the ombudsman has found. 

Provincial ombudsman Mary McFadyen released her 2021 annual report on Thursday.

The ombudsman's office received 3,811 complaints, 188 of which were about the SHA.

McFadyen highlighted a long-term care investigation about a resident, given the pseudonym Sophia, who had a high risk of falling. In fact, she fell out of bed on her first night but staff quickly found and helped her because her bed alarm sounded, the ombudsman's report says. Additional fall-prevention safeguards were added to her plan.

However, a few days later, Sophia was found on the bathroom floor bleeding, seriously injured and unresponsive.  She was taken to hospital and died three days later.

Sophia could have been lying on the floor for up to an hour and 45 minutes, according to information provided to the ombudsman.

Care plan not properly implemented

After Sophia's first fall, her care plan was updated, requiring:

  • A bed alarm while she was in bed.
  • A hip protector during the day.
  • A call bell within reach.
  • A bed check by staff at a minimum of every two hours throughout the night. 

As well, whiteboards were set up in her room instructing staff to set her bed alarm, and to help her to the bathroom twice during the night.

Despite having a plan that met Sophia's needs, the SHA failed to properly implement it, the ombudsman found. 

Ombudsman Mary McFadyen found that despite having a plan that met the patient's needs, the SHA failed to properly implement it. (CBC)

"Her caregivers were unclear whether her bed alarm had gone off, was not working, or even whether it had been activated when she went to bed. No one confirmed that it was working or turned on. They were also not clear about when or how many times she was checked on during the night," the ombudsman wrote in the report.

The ombudsman found no indication that Sophia had been checked on after 8:30 p.m. until 3:00 a.m. — a 6½-hour gap.

"Though there is no way of knowing for sure, she likely fell because she got up to go to the bathroom by herself. Had the bed alarm gone off and a staff member responded to it immediately, she may not have fallen at all," the ombudsman said.

"Even if she had, she would have been found, and her injuries would have been assessed and attended to much earlier."

Incident report not completed properly 

The ombudsman found that the incident report that staff filled out after Sophia's fall was not completed properly, noting irrelevant things while failing to note things that were important. For example, the form said it wasn't applicable whether the bed alarm was activated. 

The report said Sophia fell because she had a stroke, but the ombudsman said it's "misleading" to note a stroke as a possible contributing factor but not include the alarm. 

"In any event, she fell because she was out of bed on her own and heading towards or away from the bathroom without any help — precisely the situation her care plan was designed to avoid."

The SHA was also required by law to give the Ministry of Health notice of Sophia's fall and death within three business days but didn't do so unitl 15 days had passed. The SHA only took steps to confirm Sophia's case was a critical incident 10 days after her family contacted the health authority.

In addition, the ombudsman found issues with the critical incident review that the SHA was required to conduct, including that the official assigned to conduct the review had never been trained to do it. 

The team involved in this particular incident "has made several improvements," including training on the use of bed alarms, regular audits on bed alarm functionality and education on doing rounds, according to SHA communications consultant Jocelyn Argue.

"We take safety and care-related concerns very seriously," Argue wrote in an email to CBC News.

Forty-two infected people died during the Extendicare Parkside COVID-19 outbreak from November 2020 to January 2021, including 39 people whose deaths were caused by COVID-19. (Richard Agecoutay/CBC)

In August 2021, the ombudsman released a damning report that found Extendicare Inc. was "clearly not ready to manage" the COVID-19 outbreak that killed 39 residents at its Parkside nursing home in Regina from November 2020 to January 2021.

McFadyen's report lays out four recommendations to Extendicare, including a call for the company to apologize in writing to the families of residents who died because of the outbreak.

But Extendicare hasn't accepted any of the recommendations, according to the ombudsman's latest report. 

"In my view it is their responsibility to provide an apology," McFadyen told reporters on Thursday. "There's no reason for them to not apologize to those families."

Extendicare said it has implemented all the recommendations in the ombudsman's report.

"Under the co-management agreement in place with the Saskatchewan Health Authority, we continue to work collaboratively with them in the best interest of residents and their families," the company wrote in a statement to CBC News after McFadyen's comments. 


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