Long-term care home inspections in Thunder Bay, Ont., show concerns of neglect

Long-term care homes across Ontario have been under scrutiny in 2020, in light of many deaths and reports of care issues during the COVID-19 pandemic.

While homes in Thunder Bay have not seen outbreaks of COVID-19 as some have seen in southern Ontario, CBC News did look at all of the publicly available inspection reports provided by the Ministry of Long-Term Care for 2020.

Much of the information in the reports is generic, and the incidents themselves lack detail on what would have actually transpired to result in an investigation.

In Thunder Bay’s six homes, Southbridge Lakehead, on South Vickers Street, had only one documented incident. It’s when a resident died unexpectedly, but an investigation revealed no follow up actions were required.

Southbridge Pinewood also had one critical incident inspection in January, which covered three issues, being missing or unaccounted controlled substances, a missing resident (who was later found) and improper treatment of several residents.

Largest home in Thunder Bay

The home with the most critical incidents and complaints in the city is Hogarth Riverview Manor (HRM)

The facility is also the largest in northwestern Ontario, with 543 beds, as listed by the Ministry. It also notes that the home is still operated by Extendicare, and is licensed to St. Joseph’s Care Group.

HRM had five critical incident inspections by October 2020, along with three inspections based on complaints.

In those inspections, a number of separate incidents can be investigated.

In a report filed in August, HRM was noted to have five issues involving incompetent or improper case, 18 issues with alleged resident-to-resident abuse, 11 issues involving staff-to-resident abuse and neglect.

Other issues regularly found in the inspection reports involve issues with wound care, and in one case, residents not being placed near communication devices, or call bells, while performing a certain activity.

In one example, a staff member at HRM used a mechanical device to lift a patient, but did this task on their own. Policies state that two employees should be operating the device for safety reasons.

The employee said they were too busy during their shift, and could not get all of their work complete, so they sent their colleague to another area of the home to complete a task, while they operated the lifting device on their own.

Other items flagged in the reports include a resident not getting their proper meal, and residents who are in restraints not being properly monitored.

A person who stocked storerooms at HRM said the list of supplies required for each floor, which varies due to the needs of various people who live on a particular unit, went missing, and “went by memory” to bring items to floors like incontinence products, and other sanitary supplies.

Other homes

The three other homes in Thunder Bay also had a variety of issues, including problems with continence for those who live in the homes.

Bethammi Nursing Home, also licensed to St. Joseph’s Care Group, had an incident in February where a resident was moved to their bed, and then found deceased.

The inspection noted that the resident’s care plan was not properly followed, and the person was placed in the wrong position, along with other items being in the wrong position for proper care. A bed safety rail is also noted as being an issue in the report.

Bethammi also had issues with rounds and documentation not being completed on time, as well as issues with falls and fractures with residents.

Southbridge Roseview had issues with residents not having their specific care plans followed, and failing to use restraints only when a resident or Power of Attorney had agreed to it.

The home also had issues with medications not being properly stored, which the inspector wrote had also happened before.

One incident, which was investigated in May, involved a resident who was aggressive toward others. While staff had tried a number of interventions over a variety of days, the effectiveness of those interventions was not properly documented to know exactly what was working.

It turns out, the report said, the resident wanted their hand held during certain activities.

Issues with skin conditions were commonly noted, including an investigation at Pioneer Ridge in May.

In one of the three residents this problem was found, the documentation between 2019, when the issue originated, and 2020 had the same skin issue occurring on a different part of the resident’s body. 

Pioneer Ridge also had not updated its infection control plan annually, a report noted. 

Most of the issues noted by inspectors were rectified for the homes by either undertaking retraining for staff, or updating documentation.

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