Appendix: Summary of 2023 cases and recommendations

Acute Care and LTC Industry/Other:

1. Physicians should continue to assess patients in person even during a pandemic and should carry out a physical examination pertinent to the presenting complaints.

Other:

2. Physicians should be reminded that, in the presence of generalized edema, causes other than cardiac disease should also be considered.

Communication and Documentation/Acute Care and LTC Industry:

3. Hospital staff should be kept apprised of home care supports available in LTCHs. Transitions of care are associated with increased risks. Person to person, ‘warm handovers’, should be done when transferring patients between facilities.

Communication and Documentation:

4. If services are requested from Home and Community Care Support Services (HCCSS) and not provided, this information, along with alternatives, should be provided to the facility caring for the patient.

Medical and Nursing Management/Communication and Documentation

1. All retirement homes should be reminded of their obligation under the Retirement Homes Act (RHA) to have an accurate current plan of care for each resident.

Medical and Nursing Management/Communication and Documentation

2. All retirement homes should be reminded of their obligation to communicate clearly with substitute decision makers in a timely and fulsome manner with regards to a resident’s care.

Communication and Documentation

3. Retirement homes and the Retirement Home Regulatory Authority (RHRA) have a responsibility to ensure a safe physical environment for residents according to the Retirement Homes Act. This includes ensuring that individuals with dementia, who might be unable to understand signage or elevator function, are not able to access elevators without supervision.

Education and Training

4. The Retirement Homes Act should be reviewed to ensure that resident safety is prioritized, particularly in light of the growing number of residents with complex medical needs.

Other

1. An Occupational Therapy safety assessment should be considered in circumstances of wandering with elopement risk.

Other

2. Safety solutions such as wander-guards, Apple tag devices, and balcony locks, should be considered in circumstances of wandering with elopement risk.

Medical and Nursing Management

3. Involvement of the resident’s family physician should be encouraged from an early point if any behavioral or medical issues arise with a resident.

Medical and Nursing Management/Acute Care and LTC Industry

4. In light of the increasing medical complexity of residents, the Ministry should consider appropriate regulation (physical aspects of accommodation, minimum staffing levels and qualifications, medication delivery), to improve the safety of residents.

Other

5. The Ministry should consider funding the RHRA to enable it to better fulfill its mandate to protect the safety of residents.

Other

6. The RHRA should be given increased authority (such as ability to levy fines) to enforce the requirements of Retirement Homes Act.

Other

7. The Ministry should continue to pursue the policy of differing license classes of Retirement Homes to better meet increasing safety risks of this population.

Communication and Documentation

1. Review assessments for safe use of electric wheelchairs to include consideration of behavioural symptoms such as aggression, irritability, and impulsivity.

Acute Care and LTC Industry/Education and Training

2. LTCH staff should be reminded that wandering/exploring behaviours can pose a risk to the individual resident and their co-residents in LTC. Mitigation strategies should include education of family and caregivers about these risks when residents with such behaviours are present on the unit.

Communication and Documentation/Education and Training

3. Strategies should be developed to address aggressive and impulsive behaviours that are not specifically related to dementia and to ensure access to specialized services for assessment and management approaches.

Communication and Documentation/Acute Care and LTC Industry

4. LTC homes should have ready access to ethics consultation when ethical dilemmas are presented to the care team.

Communication and Documentation/Acute Care and  Industry

1. The psychiatric hospital should explore ways to expedite communication between the ward, front line staff and physicians when there is a significant change in a patient’s clinical status.

Acute Care and LTC Industry

1. The Ministry of Seniors and Accessibility and RHRA should review the need for security standards for retirement homes that provide secure units. This should include window security.

Medical and Nursing Management

2. In light of the increasing medical complexity of residents, consider appropriate regulation (physical aspects of accommodation, minimum staffing levels and qualifications, medication delivery), to improve the safety of residents.

Acute Care and LTC Industry

3. A quality review of the circumstances of this death should be completed, including consideration of perimeter security.

Acute Care and LTC Industry

4. When patients with dementia are discharged to retirement residences, decision makers must consider that these residences do not offer dementia or behavioral management services and are not staffed for such.

Education and Training

1. Medical and nursing directors of all Emergency Departments should be familiar with the free open-access resource "The Elder Mistreatment Emergency Department Toolkit” (gedcollaborative.com).

Determination of Capacity, Consent for Treatment, and DNR

2. Capacity assessments for health care decision making must be conducted with the use of a trained interpreter wherever possible and access to trained interpreter services should be available to staff 24/7.

Communication and Documentation

1. All clinical staff in complex chronic care facilities should be reminded of their duty to report deaths as outlined in Section 10 of the Coroners Act.

Communication and Documentation

2. A family meeting, including the participation of the attending physician, should occur within the first few weeks of an admission to a complex chronic care hospital.

Communication and Documentation

3. All health care providers and facilities should be reminded that timely and accurate disclosure of patient safety events is essential in maintaining the trust of patients and families in the health care system.

Education and Training

1. Staff should be regularly trained on the proper use and fitting of a mechanical lift and sling.

Use of Drugs in the Elderly

2. Healthcare providers should be reminded that non-steroidal anti-inflammatory drugs (NSAIDs) increase the risk for hemorrhage/bleeding, and they should be used with caution in the elderly.

Use of Drugs in the Elderly

3. Healthcare providers should be reminded that medications prescribed to the elderly must be appropriately dose adjusted for renal impairment.

Use of Drugs in the Elderly

4. Healthcare providers should be aware of drug-drug interactions that may increase anti-coagulant effect.

Use of Drugs in the Elderly

5. Healthcare providers should be reminded that the quarterly legislated medication review is more than just a renewal of the medications. The review should include the physician, nursing and the pharmacist.  The review should be a thoughtful look at the patient as a whole, considering age, weight and frailty.

Medical and Nursing Management/Education and Training

1. Healthcare providers are reminded that where a fall may have contributed to death, the coroner is to be contacted promptly.

Communication and Documentation

2. RHRA should develop quality care standards for the safe and compassionate care of residents with dementia, including the behavioural and psychological symptoms of dementia.

Acute Care and LTC Industry

3. Retirement homes should refer patients to long-term care when the patient’s care needs grow beyond the capacity of the retirement home to provide safe care.

Communication and Documentation

4. Retirement homes should have clear policies and procedures on how independently employed staff interact with retirement home staff.

Medical and Nursing Management

5. For residents coming into retirement homes with complex behavioral health needs, early referral at the time of admission to locally available behavioral and/or mental health supports is strongly recommended.

Acute Care and LTC Industry/Education and Training

1. The LTC home should review its palliative approach to care including the involvement of the attending physician/most responsible physician (MRP) and medical director. There should be education and support provided to the nursing staff on end-of-life assessment, symptom management and use of palliative medications. There are many education initiatives available to support interprofessional team-based education and this would be recommended for this team including the medical staff.

Medical and Nursing Management

2. Develop a relationship with external palliative care providers to provide clinical support and capacity building for end-of-life care.

Medical and Nursing Management/Acute Care and LTC Industry

3. Given the increased complex care needs and decreased length of stay across LTC homes, all LTC homes should develop internal expertise in palliative and end-of-life care. Palliative care programs should include end-of-life order sets to guide best practices noting that these must be individualized to the resident’s medical status and care needs.

Medical and Nursing Management/Use of Drugs in the Elderly

4. End-of-life orders should also include careful review of previous orders to review other medications, such as psychotropics, that when stopped may cause withdrawal symptoms.

Medical and Nursing Management/Acute Care and LTC Industry

5. Physicians should be aware of the leadership role they play in the provision of palliative care in LTC homes. Reliance on external teams does not replace the ongoing continuity of care required as attending physician (MRP). An acute change in status and implementation of end-of-life management warrants an assessment by the MRP.

Medical and Nursing Management/Communication and

Documentation/Use of Drugs in the Elderly

6. Physicians should also be aware of their responsibility when providing telephone orders. Orders should be read back to the prescriber by the nurse after they have been provided to confirm that the direction in the order is correct. In particular, for high-risk medications, such as in this case, the physician/prescriber should document in the progress notes of the electronic health record in the absence of a Computerized Provider Order Entry (CPOE) system in place.

Communication and Documentation

7. Explore mechanisms to implement closed loop medication management systems including CPOE with a fully integrated medication management system. A collaboration with OntarioMD should be explored to implement more sophisticated electronic medical records for LTC including robust CPOE.

Acute Care and LTC Industry

1. All exit doors should be locked and have an auditory alarm.

Communication and Documentation/Acute and LTC Industry

2. Review Code Yellow procedures to include immediate review of video surveillance available, especially in the winter months. Police should be notified as soon as possible of a missing person who may have left the building.

Acute Care and LTC Industry

3. Video surveillance should be used on all entry and exit doors.

Medical and Nursing Management/Acute Care and LTC Industry

4. Ensure that as the dementia progresses, there is a regular reassessment of the resident’s needs and care environment carried out by the appropriate health care professional.

Medical and Nursing Management/Acute Care and LTC Industry

1. Staff should be reminded that the use of standardized tools to assess pain is mandatory in Ontario and serves a useful purpose.

Medical and Nursing Management/Acute Care and LTC Industry

2. Dehydration is a common issue in frail elderly LTC residents.  Each LTC facility should have robust procedures to intervene early and manage effectively.  Early assessment by a dietitian can be extremely helpful.

Medical and Nursing Management/Acute Care and LTC Industry

3. Some LTC residents are appropriate for treatment for osteoporosis, particularly those who are mobile and experiencing falls.

Medical and Nursing Management/Acute Care and LTC Industry

4. When the clinical status of a patient changes, enhanced physician involvement (in association with the interprofessional team) is very important.

Medical and Nursing Management/Use of Drugs in the Elderly/Acute Care and LTC Industry

5. Falls prevention requires a comprehensive assessment.  While physical improvements can be beneficial (lower beds, bedside mat), disease optimization, and drug review are also very important.

Use of Drugs in the Elderly

6. Regular drug reviews should not be ‘pro forma’ as there is accumulating evidence that deprescribing many drugs can be beneficial. GeriMedRisk can be used as a resource.

Medical and Nursing Management/Use of Drugs in the Elderly

7. Prescribers should be reminded that there are no medications that are effective for wandering.

Education and Training

1. Publicize information on elder abuse and neglect.

Communication and Documentation

2. Consider official helplines (for example, Toronto Seniors Helpline, Seniors Safety Line).

Education and Training

3. Provide seniors help-packages to the public.

Education and Training

4. Develop and publicize educational materials for caregivers to increase knowledge about homecare, respite care and other services available.

Other

5. Consider an elders protection system akin to child protection, and specific legislation to target abuse and neglect of elders.

Other

6. Fund research into elder abuse and neglect in Ontario.

Medical and Nursing Management

7. Formalize and fund home visits by MDs/Nurse Practitioners/paramedics/social workers with special emphasis on psychiatric diagnoses and barriers to accepting help.

Education and Training

8. Police training programs should be developed to teach police about investigation of elder abuse.

Education and Training

9. Consideration should be given to check sheets and best practice guidelines for use by officers investigating elder abuse.

Communication and Documentation

10. Investigators should consider discussion with Crown Attorneys in cases of possible elder abuse or neglect.

Communication and Documentation

1. This incident of entrapment and positional asphyxia related to a device, must be reported to Health Canada if not done so already under the mandatory reporting criteria.

Education and Training

2. The committee feels there is a lack of research into the safe use of assist poles in long term care, RHRA and private dwellings. Research into the use of assist poles is essential in determining overall safety profile of these devices. Health Canada should make recommendations for specific distances when installing transfer poles similar to recommendations for prevention of bed entrapment.

Communication and Documentation

3. Manufacturers of transfer pole devices should provide specific measurements for installation in the instruction guide that accompanies the pole. The committee suggests that the pole be placed at a distance further than the width of the person using it and not close to the bed. Beds or furniture should be fixed or against a wall to prevent movement which might create an entrapment gap.

Communication and Documentation

4. Instructions should include warnings of potential entrapment for devices used by persons with dementia and/or risk of falls.

Education and Training

5. This case should be forwarded to the College of Occupational Therapists to be included in education regarding safety of equipment used by persons with a risk of falls with or without dementia.

Acute Care and LTC Industry

6. The RHRA should expand their mandate such that an incident review addresses the preventable causes of the incident and not just compliance with the regulations. The inspection system should be tied to legislation, safe environments and systems quality improvement.

Communication and Documentation/Acute and LTC Industry

7. The RHRA should consider a policy of investigating all non-natural deaths.

Acute Care and LTC Industry

1. Doors should not have the key nearby —consider keypads with regular code changes.

Acute Care and LTC Industry

2. Door alarms should be specific to the specific open door and not share alerts with high frequency alerts like resident requests.

Education and Training

3. Safety protocols should be reviewed and updated regularly.

Acute Care and LTC Industry

4. Maintenance requests that could impact resident safety, such as lighting deficiencies and malfunctioning outside doors, should be submitted by any staff member who finds them.   They should be treated as urgent.

Acute Care and LTC Industry

5. Doors found unlocked should automatically trigger a missing resident response.

Education and Training

6. Missing resident response drills should be practiced regularly, especially when agency staff who may not be familiar with the home are present.

Acute Care and LTC Industry

7. Regulations should include that door alarms should be specific to the specific open door and should not share alerts with high frequency alerts (like resident requests).

Acute Care and LTC Industry

8. Funding programs should be considered for residents with high elopement risk (elopement bracelets, GPS devices, shoe imbedded GPS devices, and so on).