Appendix A: Summary Of 2019 cases and recommendations

1. This case should be used as an educational tool to inform physicians and pharmacists about possible adverse reactions from the co-administration of verapamil and dabigatran.
2. Physicians are reminded that community pharmacists are an important part of the health care team.  Alerts from the pharmacist related to high risk medications should be carefully considered. 3.
3. Physicians are reminded that close follow up and reassessment of patients for side effects is necessary when initiating high risk medications.

1. All critical incidents leading to serious injury and death occurring in long-term care should be investigated in a timely fashion.
2. If a resident is recognized to have behavioural care needs beyond which can be accommodated with usual care in a long-term care setting, and the resident is waiting for further assessment and care in a specialized environment, then supports should be put in place in long term care to safely care for the resident while waiting to access another level of care.
3. Behavioral Support Ontario resources should be made available to all long-term care homes across Ontario to a degree that enables safe care of residents with dementia.

1. The “normalization” of violence should be considered when developing the Ontario Provincial Dementia Strategy by the MOHLTC. 
2. Consideration should be given to increasing high-needs funding for long-term care facilities. 

1. The MOHLTC should consider, as a component of the configuration of a system-wide approach to responsive behaviours/ behavioural and psychological symptoms of dementia (BPSD), the establishment of an increased number of non-transitional long-term care home behaviour support units for carefully selected individuals with severe and prolonged behavioural symptoms, adequately resourced and staffed, with individuals trained to manage BPSD, throughout the province.
2. There should be a continued increase in resources to support training and education of long-term care home staff and physicians in the management of responsive behaviours/ behavioural and psychological symptoms of dementia (BPSD), as well as to support increased staffing levels in long-term care homes, not through high-intensity needs funding (which is responsive), but through increased general staffing (which is proactive).
3. When working with patients with complex presentations involving male sexual aggression or disinhibition, geriatric psychiatrists are reminded to consider anti-androgen therapy (e.g. cyproterone acetate or progesterone products), rather than adding more trials of psychiatric medications with sedative side effects.

1. Long-term care staff are reminded that documentation should be completed as soon as possible after a safety incident in order to avoid recall bias.
2. Recommended safety procedures and individual patient care plans should be adhered to.
3. Outdated and/or unsafe transfer and bathing equipment should be reviewed at regular intervals and replaced accordingly.
4. Multidisciplinary quality improvement rounds should occur to review injuries (explained and unexplained) and to promote a culture of safety within the institution.

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1. The MOLTC should assess the appropriateness of having four-person rooms for residents (particularly with cognitive impairments) in long-term care homes. 

1. The Ministry of Health should consider regulating personal support workers (PSWs) in order to establish a consistent and standardized level of service for care providers in the PSW role.
2. Long-term Care Homes are encouraged to create a working environment that engages staff to identify and address concerns and errors in an open and honest manner.

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1. Care providers in long-term care homes are reminded that responsive behaviours need a thoughtful approach addressing causative and relieving factors in an organized manner. "Responsive behaviours" is a diagnosis of exclusion once other causes have been ruled out. Individuals with intellectual delay and dementia are particularly vulnerable to having physical causes of behaviours overlooked.
2. On discharge from hospital, findings and treatment recommendations must be clearly communicated to the family and care team at the long-term care home.  All recommendations should be discussed with the patient/resident and or substitute decision maker and reviewed with the long-term care team to guide a plan of care based on new findings in hospital.
3. Short term behaviour management teams and units cannot fully meet the needs of those with chronic behaviours.  Long-term facilities should be available and appropriately resourced for the ongoing care of those with challenging behaviours. 

1. When an individual has been apprehended by the police under the Mental Health Act, a short, written summary of the reasons for apprehension should be provided to the receiving hospital, both as a record of events and as evidence that the patient was apprehended under the Act.
2. A pattern of escalating aggressive behaviour in the presence of psychosis where there is an underlying major neurocognitive impairment is a known risk factor for physical violence, impulsive decisions and possibly suicide and/or homicide. Hospital admission to establish clear diagnosis and establish an effective treatment plan may be required prior to safe re-integration into the community.
3. For specific high-risk transitions between hospital and home, it is essential that clear communication and treatment plans be established and maintained.
4. Rapid, easy access to respite beds for community crisis should be accessible within 24-48 hours for dementia patients/families in crisis.

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1. Long-term care homes should have a process for tracking and flagging violent behavior of residents. This process should trigger a mandatory multidisciplinary team review that should, in turn, encourage the involvement of expert support services.

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1. Mobile x-ray services should be readily available to all long-term care homes in the province, including access on weekends.
2. Long-term care clinicians and staff are reminded of the risks of fracture with minimal traction force in people with osteoporosis, including those with non-weight bearing status.
3. Clinicians should utilize the Fracture Risk Scale (FRS) generated from MDS-RAI assessments to identify those residents at high risk for fracture.
4. Medical researchers should recognize an opportunity for research on low trauma fractures and fractures with no apparent injury or minimal trauma.

1. Healthcare providers are encouraged to develop and utilize a controlled access system for “as needed” (i.e. PRN) medications.  This may include having the medication only available as ordered or requiring sign off by more than one healthcare provider when PRN doses are administered. 
2. Electrocardiograms (ECGs) should be completed for all patients admitted to hospital on QT prolonging medications and there should be increased knowledge and communication between clinicians and pharmacists about QT prolonging medications and the in-creased risk of arrhythmias. Pharmacists should consider reviewing prolonged QT algorithms for patients.
3. Consideration should be given for the use of a stepwise or rational approach to prescription and dosing medications in behavioural and psychological symptoms of dementia (BPSD) .
4. The hospital involved should conduct a document audit relating to the care provided to the decedent. 
5. Hospitals should consider:
   • psychiatric or specialized behaviour ward admission for geriatric patients with behavioural issues;
   • increased funding for education to nurses outside geriatric psychiatry (e.g. PEICES education for non-psychiatric wards);
   • increased funding for sitters/attendants for patients with responsive behaviours;
   • dedicated geriatric psychiatric behavioural units (such as tertiary care beds) to lessen behavioural admissions to medical wards.

6. Healthcare providers are reminded of the mandatory requirement for patient confidentiality as per the Personal Health Information Protection Act PHIPA (2004), particularly in relation to the use of personal communication devices and the use of social media. 

1. The hospital involved should consider the involvement of a Hospital Ethicist in discussions with families regarding issues of capacity and consent. 
2. Discharge referral information (i.e. to the LHIN) should be checked for accuracy regarding correct contact information, consents and the direction of a capable client where a request to not have family involved has been made. Attention to this detail will help to mitigate delays in service provision and avoid breaches of privacy.

1. Staff and families should be reminded that when there is a change in the cognitive status of a resident who uses an electronic assistive device, and independent use of that device may no longer be safe, the controls should be removed or locked to make the device inoperable to the individual.
2. The circumstances surrounding this death and the involvement of an electronic/power lift recliner should be reported to Health Canada. 
3. The classification of electronic/power lift recliners, particularly when used as an assistive device, should be reviewed by Health Canada.
4. Health Canada should encourage manufacturers of electronic/power lift recliner chairs to modify the control pendant or install a mechanism to prevent inadvertent activation of the chair. A locking mechanism should be available on all electronic/power lift recliners.

1. The long-term care home involved should conduct a review of the circumstances leading up to the death of this decedent including how the home responds to incidents of violence and subsequent notification of police. 
2. The long-term care home should consider including all members of the care team (e.g. attending physician/RNEC (extended class), and outside behavioural support specialists/consultants, etc.) in the evaluation of residents with responsive behaviours. 
3. The long-term care home should consider developing a protocol for residents expressing violent behaviours that includes a timely comprehensive medical assessment.

1. Long-term care homes should ensure that private caregivers are not providing direct care to residents. 
2. Long-term care homes (LTCHs) should ensure that wound and skin care is provided by regulated staff and not unregulated care providers who are not employees of the LTCH.

1. Healthcare providers are reminded of a low threshold for consultation and admission for frail elderly patients with frequent visits to acute care hospital emergency departments. If they are to be discharged, a comprehensive care plan should be developed in consultation with the care team.
2. Acute care providers should be reminded of the difference in levels of care between retirement homes and long-term care homes.
3. Acute care providers should be aware of the BEERS list of potentially inappropriate medications in older adults.
4. It is recommended that a review of indications and dangers of anticholinergic agents in the frail elderly with attention to anticholinergic burden scoring, be considered.  In particular, the medication Benztropine should be used sparingly if ever in the elderly.  If Benztropine is used, it should be in younger patients, for clinically significant medication-related movement disorders, and the indication for use should be documented.

1. All facilities providing care to persons with dementia should have access to Behaviour Support Ontario (BSO) teams and geriatric psychiatry support.

1. All long-term care homes in the province should have easy and timely access to Behavior Support Ontario (BSO) teams and geriatric psychiatry support to assist in the care of residents with complex behavioural challenges as part of their dementia.
2. It is recommended that all long-term care homes in the province conduct an audit of their window and door compliance and perform yearly safety and compliance checks. 
3. All physicians working in long-term care homes are reminded that a serotonin syndrome can emerge in seniors with dementia as they age, even if they have tolerated a given dose of psychiatric medication at a younger age. The risk of developing a serotonin syndrome increases with the number of serotonergic medications prescribed.

1. Increasing frequency of falls or near falls should trigger a medical assessment including a careful review of all medications that could contribute to increased falls risk and laboratory investigations to look for a cause of increased restlessness and falls.
2. Admission to a long-term care home is an opportunity to do a thorough medication review and de-prescribe where possible.
3. Emergency preparations for power failures should include a functioning telephone to contact emergency medical services.  All staff should be aware of the address of the facility and this should be posted throughout the facility.

1. Care providers are reminded of the importance of a multi-disciplinary assessment of change in health status.
2. Care providers are reminded of the importance of maintaining adequate nutrition throughout changes in health status and environment.

1. When there is a change in the health status of a resident of a long-term care facility, nurses and physicians are reminded that a comprehensive assessment is required to diagnosis and treat whatever the underlying medical problem may be. These comprehensive assessments are to be documented using a standardized format such as the SOAP  template.
2. When there is an acute change in health status that is unexplained, and in which the resident has opted for active investigation and treatment, then a rapid comprehensive assessment must occur or emergency services (“911”) should be activated promptly.
3. The use of a standardized nursing–physician communication tool (e.g. SBAR) is recommended to be used in long-term care settings.
4. The College of Physicians and Surgeons Ontario are encouraged to prepare an article for publication in Dialogue that touches on the details of this case and focuses on communication and documentation between physicians, nurses and other members of the healthcare team.