2023-05-12 19:30:00
Employees who sleep at work, neglected residents, shortcomings in training and management: a residence in Terrebonne that houses people with dementia has been severely blamed by the ombudsman.
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The report on the intermediate residence (RI) Ressource de Lanaudière (under contract with the public network), and the residence for the elderly (RPA) Maison L’Étincelle, is troubling. Here are some examples:
– Employees have been caught “dozing off, dozing or sleeping” during their shift.
– A lady who had fallen in her room stayed all night with her foot stuck in a piece of furniture without anyone noticing.
– A beneficiary attendant disregarded the fall protocol and relieved a user during the night. The next day, the resident was taken to the hospital. He died a few days later from a fracture suffered during this fall, concluded the coroner.
Concerning events
“A number of worrying events have been brought to our attention during the investigation. Some of these events caused harm to residents,” sums up the Québec Ombudsman’s report, made public last March (see box), but passed under the radar.
Open since 2021, the RI-RPA welcomes 144 residents (in the same building). About 80% of them have cognitive deficits.
The Québec Ombudsman’s investigation followed a report last summer concerning shortcomings in user safety and the quality of care. Several training and management shortcomings were also noted in the survey.
“It’s not something we saw coming, reacts Sébastien Barrette, one of the owners of the RI-RPA. It is true that events have occurred, to our great dismay.”
In the report, we read that the staff turnover at this location was impressive: 80% of the orderlies present at the opening in 2021 had left their jobs 18 months later.
According to the ombudsman, the owner was “insistent” on speeding up admissions during the opening, “despite a lack of preparation.”
An assertion denied by Mr. Barrette, although he recognizes that the staff turnover was important, because of the pandemic.
“The team continued to put in a lot of effort, but the recipe didn’t catch on as quickly as we would have liked,” he underlines.
In the report, the residence deplored a lack of support and accompaniment from the Integrated Health and Social Services Center (CISSS) of Lanaudière.
Action plans and follow-ups
In total, the Québec Ombudsman issued 15 recommendations to remedy the situation. An action plan was transmitted by the management of the RI-RPA, confirms the ombudsman, and follow-ups will be ensured.
On this subject, Mr. Barrette assures that all the problems have been resolved since the visit, and that the retention of personnel has been much better since last fall.
According to the report, the CISSS de Lanaudière has also reviewed its fall protocol for IRs.
Disturbing findings reported
– Employees have been caught “dozing off, dozing or sleeping” during their shift.
– A lady who had fallen in her room stayed all night with her foot stuck in an element of her furniture without anyone noticing. However, all rooms are equipped with surveillance cameras.
– A beneficiary attendant disregarded the fall protocol and relieved a user during the night. The next day, the resident was taken to the hospital. He died a few days later from a fracture suffered during this fall, concluded the coroner.
– Physical altercation between a resident and an employee. The latter submitted his resignation shortly following the event.
– A resident was taken to her room and her door had been closed, to protect her from a user who had behavioral problems. However, unable to open the door alone, the lady who had cognitive impairment found herself confined.
– Residents who have neurocognitive disorders have been assigned magnetic cards to leave their unit without accompaniment. Secure unit doors also required occasional adjustment because they did not close properly.
– Beneficiary attendants refused to use the electronic tablets at their disposal, an important tool for night surveillance (via the cameras in the rooms).
– Beneficiary attendants did not know where to find essential information on medication in case of need.
Source: Québec Ombudsman
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