Monday, February 18, 2013

Violence in long-term care: assault or abuse?

W5: Crisis in Care

W5: Crisis in Care

This incident: Frank Piccolo, 'attack should have put staff on alert' (Toronto Star). He was attacked with an activity board.
For its part, the ministry did investigate. In an inspection report dated April 2, 2012, a ministry inspector found that “Lakeside had violated the Ontario Long-Term Care Act” and had failed in its “duty to protect” Frank Piccolo. 
The investigation also found that the nursing home had known for weeks that Frank’s attacker was aggressive and still left her unsupervised.

No charges were laid, according to Sup't. Dimasso, because of the capacity of the perpetrator. Both the victim and offender have dementia. The family wanted police to charge the home with negligence, pressing charges, since the perpetrator didn't have the capacity to understand what she had done. Criminal negligence is 'hard to prove.' The victim was 68 years old. He died 3 months after the attack.

The police Superintendent declared that they are 'not supposed to police nursing homes'.
It is the duty under LTC Act to provide a safe environment. Jurisdiction of MOHLTC.
All LTC homes have a Duty to Protect, according to the Act. They knew for weeks the resident was abusive. There were 8 incidents where she had attacked staff. The PSW assigned to the perp had scratches down her arm.

The majority of reported attacks are committed by residents on other residents. Physical, verbal, choking, bleeding, pushing, slapping, punching, all have been reported. PSWs are not supposed to put themselves at risk. They are able to refrain from interfering if they are at risk.

What does this mean for a resident who is a victim? The police will not charge the offender. The institution does not need to demonstrate that they can control the perpetrator, or resolve the issue.
I have seen the violence those with dementia are capable of doing and they lack the inhibitions of those with their full faculties.

How many Canadian live in long-term care?

Estimates say there are 100,000 Canadians in LTC. W5, a CTV investigative show, estimates that there are 10,000 incidents of assault, resident on resident, in one year. W5 mistakenly calls them abuse. I believe they must be called an assault, and the perpetrators dealt with, no matter if they have dementia or not. Those with dementia beating on other residents need to be controlled. If they cannot control their behaviour, the institution must take responsibility for isolating them. There is much research done on those with dementia, and the physicians and pharmaceuticals must figure out a way to sedate those who are violent.
Extendicare Canada, where this assault occurred, runs 230 long-term care homes. I is a US-based for profit institution. Most Ontario long-term care homes are for-profits, and all LTC are governed by the Ministry of Health and Long-term Care (MOHLTC) Act.

Hidden cameras by W5

Miranda Ferrier, President of OPSWA
Staff visited three different LTC homes, taking official tours, and met staff who made promises they cannot keep. For example, they stated that they had a ratio of care of 1:8. Another states 1:10. They claimed this is a government standard, according to one facility. However, standards like this do not exist. The government funds staff, it is a ratio of staff to residents, based on physiotherapists, and nurses, and means nothing. There are fewer staff on duty at night, and very few nurses in many cases. OPSWA, which represents PSWs, have found ratios of 1:99, for three floors. Their members complain about such situation all the time. In some institutions, there could be ratio of one PSW to 25 resident. They are understaffed, since there are no absolute standards.


From W5
Just how much underreporting there may be can be seen in two sets of data we received from the Mamawetan-Churchill River Health Authority in Saskatchewan. With staff using normal methods of providing data, the number of incidents in 2011 was reported to be 23.
But the health authority conducted a “Violence Identification Audit” during two weeks in September 2011. It’s a program that allows staff to anonymously report incidents.
During that two week period, in a single home with 14 beds, staff reported 89 incidents – way more than the “official” record provided to W5.

Q. Are LTC above the law? It was an assault. They failed to protect the resident/victim.
Up to individual homes to deal with it? You will get an institution that will cover their arses.
We need to differentiate it between abuse and assault. Abuse, I believe, shows intent, and happens over time.

My Recommendations

  1. Identify violent residents with dementia. Charge them with assault, these statistics can be recorded and must be reported. Ensue that they are in a locked wing.
  2. Protocol: report to family, report to police, report to MOHLTC.
  3. Put staff on alert: each LTC and MOHLTC provide extra staff for locked wings, and violent offenders.
  4. MOHLTC provides expert consultants to work with LTC.
  5. Move offenders immediately.
  6. Lockdown the perpetrator after an attack, charge them. More staff at night. Residents do not necessarily sleep well.
  7. Banish the myths of the gentle, aging senior. Deal with protecting those who are victims.

Advice for Family

Tour often, visit at irregular times.
Read reports: MOHLTC Performance Improvement and Compliance Branch, and the Office of the Ontario Ombudsman. The ombudsman has authority to oversee the ministry but is not yet empowered to investigate directly complaints about long-term care homes or hospitals, where so many Ontarians live and die.
MOHLTC Action Line at 1-866-434-0144 to lodge a formal complaint.

PSW Training

  1. Regulation and standard training of PSWs. Currently, in Ontario, there is a self-reporting registry. This is less than effective and doesn't demand minimum standards of training. 
  2. Mandatory non-violent crisis intervention.
  3. Mandatory training in Gentle Persuasive Approaches in Dementia. 


W5: Long-term care facilities may put seniors at risk
  • There were 1,788 reported incidents of resident-to-resident abuse in 2010. 
  • There are 76,000 people currently living in long-term care homes in Ontario.
  • There were 73,045 police-reported assaults in Ontario in 2010 out of an estimated population of 13,210,667.
  • There were 23 resident-to-resident assaults per 1000 people living in long-term care in 2010.
  • There had been 5 assaults per 1000 people in the general public.
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Quality and Social Responsibility Reports
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Altercations and other interactions between residents
54.  Every licensee of a long-term care home shall ensure that steps are taken to minimize the risk of altercations and potentially harmful interactions between and among residents, including,
(a) identifying factors, based on an interdisciplinary assessment and on information provided to the licensee or staff or through observation, that could potentially trigger such altercations; and
(b) identifying and implementing interventions.
Behaviours and Altercations
Behaviours and altercations
55.  Every licensee of a long-term care home shall ensure that,
(a) procedures and interventions are developed and implemented to assist residents and staff who are at risk of harm or who are harmed as a result of a resident’s behaviours, including responsive behaviours, and to minimize the risk of altercations and potentially harmful interactions between and among residents; and
(b) all direct care staff are advised at the beginning of every shift of each resident whose behaviours, including responsive behaviours, require heightened monitoring because those behaviours pose a potential risk to the resident or others.

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