With 70% of South Island residential homes rated medium or high risk, will the Ombudsperson’s report, new regulations from government, and more frequent inspections be enough to prevent the deepening crisis in seniors’ care?
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Released a week before Christmas, the BC Ombudsperson’s first of two reports on the care of seniors made a brief splash in the media before drowning under the deluge of feel-good holiday fare. That was unfortunate, because Ombudsperson Kim Carter’s report, entitled The Best of Care: Getting it Right for Seniors in British Columbia (Part 1), discusses three key issues and reveals fundamental problems in seniors care and the provincial government’s reticence to address those problems.
In previous Focus articles (see “Who Has the Right to Control Your Life?” January 2009 and “Surviving the Borg,” March 2009), it became clear that seniors could far too easily and unscientifically be declared “incapable,” “incompetent” or “mentally ill” under BC’s archaic and draconian Patients Property Act or Mental Health Act, and instantly lose all of their rights. This opened the door to a variety of ills, including medical maltreatment, abuse from staff or family members, and care homes being unresponsive to complaints. Basically, as long as seniors’ rights weren’t strong, not much institutional will or political pressure to address their concerns could be generated.
A rescue plan lay in the wings, though: A modernized Adult Guardianship Act, many years in the making with stakeholders and already passed third reading in the legislature, would replace the Patients Property Act, and provide seniors in different circumstances with a much more variegated set of powers, rights and options.
Unfortunately, as Public Guardian and Trustee Jay Chalke, Q.C. laments in his latest annual report, that “long overdue” legislative change has been postponed indefinitely by the BC Liberals, supposedly “because of economic conditions.”
In that context, it’s not surprising that the Ombudsperson would issue early–with a special sense of urgency–a preliminary list of findings and recommendations on seniors care which spotlights the rights of people she describes as “the most frail and vulnerable” of all seniors: those in residential homes.
Ombudsperson Carter’s foremost finding is that the BC government has “not adequately identified the province’s commitment to care and the rights of seniors in residential care facilities.” Secondly, she highlights that the government isn’t providing adequate, easily-accessible information about seniors’ care facilities. Thirdly, she argues there isn’t enough legally-mandated support within residential care institutions for the voices of seniors in care and their families.
To summarize: Seniors are in the dark, and have no power.
And nothing illustrates the mess this situation has created more vividly than the most recent results of health and safety inspections at local residential care facilities.
Living in nursing homes can be risky
Health and safety inspectors rate 70 percent of publicly-funded complex care residential facilities for seniors in the South Island area as “medium risk” or “high risk”. Of 20 facilities inspected prior to February 2010 (several were too new to be rated), Vancouver Island Health Authority documents identify four as high risk, and ten as medium risk.
Privately-run facilities aren’t doing much better. Out of 10 complex care facilities recently inspected, one was rated high risk and four medium risk.
According to VIHA guidelines, risk ratings take into consideration a facility’s latest routine full inspection as well as its compliance history, in order to determine “the significance of these factors in creating an unsafe environment for clients.” High-risk-rated facilities are then inspected every six months; medium-risk every 12, and low-risk every 18.
Beckley Farm Lodge in James Bay is currently rated as a “high risk” facility. After an April 2009 inspection, Beckley was cited for 16 new health and safety violations, plus eight more ongoing violations which they’d already been cited for previously. Many involved not having adequate space and not allowing clients reasonable free movement around the facility’s public areas. They were also cited for improper use of restraints, for not having “mechanisms in place to facilitate effective communication between persons in care and staff,” for not providing “safe and adequate storage” for hazardous materials, and for not having a proper client screening process “that ensures accommodation only to those persons for whom safe and adequate care can be provided.” They were cited for 23 new violations after a routine inspection in December of 2009, including for failure to do employee performance reviews and a lack of written plans to prevent patient falls. (For all inspection results for all VIHA facilities, see here.)
After a September 2009 inspection, another high-risk-rated facility, Anderson Manor Nursing Home in Fairfield, was cited for 18 violations. Many involved the absence of written “care plans” addressing the nutritional, oral health care, medication and recreational needs of patients. They were also cited for improper handling of medications and improper maintenance of medication records.
Also following a September 2009 inspection, the high-risk-rated facility Selkirk Place had four new violations and 12 ongoing violations. Along with site safety and sanitation issues, citations included not having appropriate written procedures for the use of restraints, failure to ensure that staff administering medications were following correct procedures, failure to develop nutrition plans with dietitians, and failure to ensure that “appropriate intervention is initiated when a person in care experiences a significant weight change.”
After its November 2009 inspection, Sluggett House in Central Saanich had nine violations, including obstructed emergency exits and not having sufficiently accessible first aid supplies.
The one high-risk-rated private facility, Hart House Seniors Residence in Fairfield, received seven citations in October 2009, surrounding handling of medications, oral health care plans, storage of hazardous materials, and safety of bathtubs and showers.
It’s difficult to get a clear picture of what exactly all this means. Some jurisdictions, like California, make descriptions of actual infractions in nursing homes readily accessible to the public. Due to privacy concerns, says VIHA, they only post on the web the specific regulations inspectors cited them for violating. Specific complaints mentioned in the Ombudsperson’s report, though, include call buttons going unanswered, a woman being left on a commode for 30 minutes, dried feces and mucus on floors and railings, and repeated medication errors by unqualified staff.
For their risk ratings, VIHA inspectors evaluate in a more general way 20 risk factors in six categories. At the “low-risk” end, inspectors check boxes beside statements like, “Policies and procedures meet minimum requirements for health and safety,” “Facility physical plant is safe,” and “Staff are exceptional and protect the health and safety of clients in care.”
To be rated as “high risk,” facilities would likely have to score high in at least two or three of the six categories. That would mean inspectors would check boxes beside statements like the following: “Moderate or high number of reportable incidents (with inappropriate response to maintain health and safety) and confirmed abuse allegations,” “There are recurring poor management practices which prohibit the implementation of a systematic health and safety management plan,” “Staff are, overall, unprepared, untrained and place clients at risk,” and “Facility physical plant is extremely hazardous to client health and safety.”
As far as the detailed routine inspections go, though, sometimes the medium-risk-rated facilities don’t seem to be doing much better than the high-risk-rated ones, where it’s not uncommon for inspectors to cite medication handling errors, improper use of restraints, inadequate staff performance reviews, or lack of oral health care plans.
James Bay Care Centre was rated as high risk early last year, but has improved to medium risk. Their high-risk rating came after an inspector in March of 2009 cited them for sanitary and repair problems, medication management errors, and for not keeping proper records of the use of restraints. Their medium-risk rating came after an inspector in November 2009 cited them again for not ensuring “safe and clean” conditions and “a good state of repair,” along with citing them for installing surveillance cameras without properly displaying notice, and for not providing “first aid supplies that are readily accessible to all employees.”
Other medium-risk facilities on the South Island as of February 2010 include Ayre Manor, Beacon Hill Villa, Brentwood House, Central Care Home, Greenwoods, Kiwanis Pavilion, Luther Court, Mount Edwards Court and Piercy Respite Hotel. Privately-run facilities rated “medium risk” were Amica at Douglas House, Island View Place, Joan Crescent Manor, and Sunrise of Victoria.
These risk ratings don’t include sites currently, or historically, linked to hospitals, because those fall under separate legislation. So that means risk ratings aren’t even being done for some residential facilities that have been the object of major independent health and safety investigations or court actions, like Saanich Peninsula Hospital’s Extended Care Unit or Broadmead Lodge. For these facilities, inspections don’t occur as frequently and don’t assess as wide a range of issues.
Should the ratings worry us?
Lyne England, chair of the Vancouver Island Association of Family Councils, an umbrella organization for resident and family groups connected to residential facilities, isn’t entirely surprised that such a high percent of care homes are rated medium or high risk.
“It is a large number. It’s larger than I expected,” she says. “Am I shocked? No… [I feel] sadness. It hurts my heart. It really does. It pains me.”
A nursing professional, England blames much of it on health care cuts, reductions in the number of skilled, full-time staff in residential homes, and growing emphasis on private contractors who’ll cut corners to squeeze out profits.
“I think the staffing model is not adequate to provide the standard of care you and I would want for our loved one,” she summarizes.
Does she think many care workers are in untenable situations? “Absolutely. And I have said that time and time again, and I will continue to say that to anyone who will listen…I think overall the staff try their darndest.”
Kim Macdonald, VIHA’s Regional Manager of Licensing, however, doesn’t feel the ratings results show a particularly grim picture.
“To me, the mediums are average,” she says. “You could be a facility that [out of risk factor scores of one to five] gets threes on everything. They’re not huge issues.”
In fact, scoring three in every category would indicate a particular home is “occasionally a health and safety hazard” where staff “temporarily are unable to handle emergency situations,” and health and safety policies and procedures are only “generally” effective or “usually” ensured.
How does VIHA handle facilities that are consistently violating the law?
“It’s a progressive enforcement approach,” says Macdonald. “We try to work with the facility and assist them to move towards compliance.”
Besides increased frequency of inspections, that could involve broader investigations and reports, imposing conditions on licences, or appointing an administrator.
“Beacon Hill Villa is a pretty good example of that process,” she explains. “Prior to 2004, we were noticing lots of non-compliance [at Beacon Hill Villa], so we did have meetings with them. In 2004, we did a formal report. They assured us that they would address those issues, so we recommended no action on their licence. In 2005, there were still issues. We again did a formal report, and then imposed conditions on their licence. And then you know what happened in 2007.”
In the midst of scandalous media coverage, VIHA finally appointed their own administrator to run Beacon Hill Villa until 2008. Today, Beacon Hill Villa is still rated medium risk. After inspection in January 2010, they were cited for nine violations, including for not providing “secure, safe and adequate storage areas” for hazardous materials, for not having adequate policies about visitation, and for failure in “monitoring of the nutrition of a person in care.” At a follow-up inspection in February, they were still in violation of six of those.
Macdonald admits it’s been many years since a licence was revoked in our area. “We wouldn’t want to close a large facility,” she comments. “It would have quite a negative impact on the health of people.”
Ombudsperson to the rescue?
In light of the realities for seniors in BC’s care homes, it’s not hard to understand why the Ombudsperson chose to urgently focus on residential care homes and seniors’ rights in part one of her report.
Carter didn’t discuss the stalled Adult Guardianship Act, but instead approached from a different direction. She proposed an interconnected, mutually-reinforcing trifecta of solutions: Create a “bill of rights” for residents, improve access to information about seniors’ facilities, and provide support, in law, for the voices of seniors in care and their families.
Out of 10 detailed recommendations in total, however, our government has chosen to follow only four.
The government inscrutably claimed that a centralized, searchable website describing seniors’ homes, along with basic information about things like staffing levels, care standards, extra charges, food plans and inspection results, was just too much to ask.
“I’m not a website builder, but I understand when you do something like that it’s not a super easy thing to do,” Health Services Minister Kevin Falcon told the Times-Colonist. He nevertheless then promised grandly, “[W]e will have it in place by the fall of next year,” even though it had already been made clear in a letter to Ombudsperson Carter signed by Falcon and Healthy Living and Sport Minister Ida Chong that the government wouldn’t follow Carter’s recommendation.
Similarly, instead of creating legislation to buttress resident and family councils and draw explicit lines of accountability for complaints processes, Chong and Falcon promised to implement the “intent” of those particular Ombudsperson’s recommendations “through policy.”
Carter wrote in reply that the government’s decision “means these changes will be less durable and their implementation more subject to individual discretion.”
Less diplomatically: By relying on the existing anaemic, ineffective mechanisms and simply adding more verbiage to noble-sounding guidelines, the government’s approach will have no teeth.
The government did agree to create a new Residents’ Bill of Rights, which has already been enacted in law. But Carter had hoped that the bill would guarantee seniors in residential care reasonable expectation of receiving “assistance with basic needs such as eating, moving around and going to the bathroom” and being informed about how to “enforce their rights.”
However, in its final version, the government dropped most of Carter’s practical suggestions. Instead, their new bill proclaims a resident has rights “to the protection and promotion of his or her health, safety and dignity,” “to have his or her lifestyle and choices respected,” and “to participate in the development and implementation of his or her care plan.” Essentially, the final bill ended up sounding more like a vague, unenforceable UN declaration than a workable piece of legislation. Where it does become specific, it’s usually emphasizing rights already enforced under other legislation, like the right to view inspection reports and be informed of fees being charged to you. The government also added broad limitations, clarifying that any of your rights can still be taken away if your caregivers deem it better for your own health, mental health or safety, and forbidding you from suing even if your rights are taken away improperly.
Don’t such limitations obviate the whole point of the bill of rights?
“It’s a little like when you look at the Charter [of Rights and Freedoms] and say, do you have the right to freedom of expression? Section one says, ‘Sure, subject to such reasonable limitations that are demonstrably justifiable in a free and democratic society,’” answers Carter. “You’re hard put to get any unqualified right, ever. But I think here that, with the Residents’ Bill of Rights, it’s a good step forward… It’s something that can be built on.”
Kathleen Hamilton, who helped draft a criticism of the Residents’ Bill of Rights for the Vancouver-based Association of Advocates for Care Reform, agrees it’s a good beginning, but unfortunately one short on pragmatics.
“[The bill] puts a great deal of emphasis on ‘care plans,’ which is wonderful,” she says. “But a care plan is, well, I guess you could say, it’s the blueprint for building a house. It doesn’t mean the house is ever going to be built.”
Further, without better information about what’s going on in care homes, stronger resident and family council voices, and improved monitoring and accountability throughout the system, how useful can any bill of rights be?
“I would certainly say that these recommendations were interconnected,” comments Carter. “And so the strength of one was supported by the others. So to the extent that they aren’t implemented together, that reduces the effectiveness.”
She therefore calls the government’s overall response so far “disappointing.”
“Nothing that was recommended here hasn’t been done somewhere else…We thought these were relatively simple, straightforward recommendations.”
Carter also points out that her recommendations would benefit care workers and government, too, by clarifying expectations, resolving conflicts more quickly, and helping identify systemic problems and solutions.
So why would the government be so intractable?
Lyne England believes the government is wary of helping strengthen information-sharing systems or organizations that could lead to more criticism of it. For instance, she notes, “VIHA has historically touted that they support family councils, but over the past year and a half that certainly hasn’t been the case.” She also points to a case several years ago when she was trying to help bring family councils together to form a regional voice, and VIHA told her to “cease and desist.”
But why would the government avoid committing to even the most basic standards of care, like the right to be helped to a bathroom in a timely fashion?
Obviously, committing to standards of care would then require the government to provide sufficient funding to maintain those standards. On the other hand, if the BC Liberals’ actual primary goal is to continue selling off facilities and privatizing seniors’ care, as they have been doing, why invest in maintaining standards in the public system?
Perhaps the Ombudsperson’s main report, due by summer, will help catalyze growing public concern.
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Originally published in Focus, March 2010. Some minor corrections have been made to the published text, including clarifying that Lyne England is still a licenced nurse and that the government’s letter to the Ombudsperson was signed by both Falcon and Chong.
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