If you ignore the problems they morph into bigger problems. In the case of Elizabeth Wettaufer there were problems that were noted and she was fired. Where was the nursing association in this business? Why was she allowed to continue nursing despite the troubling history of medication related problems? Did she receive remedial training? Was there help for her mental illness?
In other words, there are many signals before major disasters happen. At the Lacombe Long Term Care we have four years of accommodation records that we know of that have problems cited. We have now got a CCHSS audit thanks to the Wildrose Party. This place is run by AHS. So what appears to be in place is tolerance for non-compliance and ongoing "mentoring" by AHS staff that does not solve problems or does so very slowly. What this indicates to me is a culture of acceptance of substandard work and the only purpose of the standards of care in Alberta seems to be to pull up the standards when the media is involved. Government doesn't work and we only get to see the extent of how it does not work when there are nursing students at Lacombe long term care, fired workers at Cold Lake Points West Living facility and a mother rushed out of another facility in Grande Prairie to speak of the "anomaly" in the system which is being spoken of in the Elizabeth Wettaufer case. The anomaly may be that we got to find out about these deaths. But what about the harm, neglect and abuse that is well known to the GOA and it's health authorities? What of these cases?
AHS investigation discovers serious problems at Lacombe long-term care facility
Published on: May 9, 2017 | Last Updated: May 9, 2017 9:22 PM MDT
The Lacombe Hospital and Health Centre BRICE ROY/LACOMBE GLOBE/QMI AGENCY / POSTMEDIA
Three staff members at a Lacombe long-term care facility have been placed on leave after an internal Alberta Health Services investigation discovered training deficiencies, unsanitary conditions and a lack of safety around medications.
The health authority said Tuesday the Lacombe Hospital and Health Centre has been thoroughly cleaned. Education sessions have also begun for staff “to ensure they understand health service and accommodation standards for continuing care.”
A total of 75 residents live in the long-term care portion of the health centre, all of whom have been re-assessed.
AHS initiated a review and audit only after nursing students completing their practicums at the site came forward with problems they had witnessed.
“We take these concerns very seriously and we responded quickly with our investigation and audits with support from Alberta Health,” Brenda Huband, chief health operations officer for central and southern Alberta, said in a written statement Tuesday.
The statement was released shortly after the Wildrose Party highlighted the issue during question period in the legislature and released leaked documents from the audit.
According to the documents, the investigation uncovered:
• Inconsistently updated care plans and patient charting;
• Incomplete fall risk assessments, dietary assessments, vital signs monitoring and wound care interventions;
• Deficient training for staff in infection control, medication management, dementia care, CPR, use of restraints, fall prevention and choking response;
• Improper security of private client information;
• Presence of expired aseptic supplies such as wound care products and catheters;
• Dirty products stored with sterile products;
• Used client razors left unattended, and tubs found to be dirty;
• Soiled linen and garbage found to be overflowing into hallways;
• Unsafe medication practices, including a client administering his own insulin when it was unclear if he was competent to do so;
• Medication rooms left unlocked;
• Poor documentation around whether clients had received required tooth brushing and bathing;
• Inconsistent practices to ensure safe water temperatures for bathing;
• High infection rates and antibiotic use.
Could a public inquiry prevent more nursing home murders?
Advocates for seniors in long-term care say abuse is too frequent and needs more attention
By Meagan Fitzpatrick, CBC News Posted: Jun 01, 2017 7:53 PM ET Last Updated: Jun 02, 2017 6:14 AM ET
Susan Horvath, daughter of Arpad Horvath, one of former nurse Elizabeth Wettlaufer's victims, holds a photo of her father as she speaks to the media outside the court house in Woodstock, Ont., April 21. There are calls for a public inquiry into the case. (Dave Chidley/Canadian Press)
Meagan Fitzpatrick is a multi-platform reporter with CBC in Toronto. Before returning to her hometown she worked in CBC's Washington bureau for several years, including 2016, which meant covering the historic presidential election. Prior to heading south of the border Meagan worked in CBC's Parliament Hill bureau. She has also reported for CBC from Hong Kong.
Advocates for elderly nursing home residents say the case of Ontario nurse Elizabeth Wettlaufer, who pleaded guilty Thursday to murdering eight of her elderly patients and trying to kill four others, must be addressed with a public inquiry.
A courtroom in Woodstock, Ont., in the southwestern part of the province, heard graphic details Thursday about how Wettlaufer used lethal injections of insulin to kill the people in her care. She confessed to the murders in a taped interview with police last fall.
"It makes it so clear that these vulnerable people faced evil," said Wanda Morris, vice-president of advocacy for the Canadian Association of Retired People (CARP) in an interview with CBC News. "And I'm hoping that the sheer horror of it will result in some further action."
Her group is calling for a public inquiry, either at the provincial or federal level.
Morris said while there are many good nursing homes operating across Canada, abuse happens far too regularly. The scrutiny of an inquiry is needed to examine how long-term care homes deal with abuse and unexpected deaths, she said.
"This was extreme," said Morris. "But there isn't a week that goes by where we don't hear about neglect, abuse, or just simply disinterest so that our most frail elderly are left without protections in a facility that is meant to care and protect them."
Fired from nursing home
Wettlaufer's guilty pleas draw part of the story to a close, but questions persist about how her actions went undetected and how to prevent something like this from happening again.
The nurse's actions only came to the attention of police when Wettlaufer told people at the Centre for Addiction and Mental Health in Toronto what she had done. CAMH staff contacted the police in September.
Wettlaufer enters the Provincial courthouse in Woodstock, Ont., Wednesday. She pleaded guilty to eight charges of murder and four attempted murder charges. (Peter Power/Canadian Press)
Details that have emerged in and outside of court suggest that red flags were raised much earlier, including a concerning pattern of behaviour at her workplaces.
Wettlaufer was employed by Caressant Care for seven years before she was fired in March of 2014. She was terminated because of a "serious" incident where she gave the wrong medication to a patient.
It wasn't the first mistake. According to police records, she had an "extensive disciplinary record" for medication-related errors, was suspended numerous times and given multiple warnings.
In her termination letter, Wettlaufer's boss said her behaviour put residents at risk.
Seven of the deaths occurred at Caressant Care.
Despite her problematic employment record from Caressant Care, Wettlaufer maintained her nursing licence and continued to find work through various staffing agencies. She was working in a London facility in 2014 when the last of the eight patients died.
Case 'an anomaly'
Wettlaufer contacted the College of Nurses of Ontario to resign her licence after police began their investigation.
Advocates who support an inquiry say the college's role could be examined in the process.
Candace Chartier, CEO of the Ontario Long-Term Care Association, said the Wettlaufer case is not the norm and would have been difficult to prevent.
"We're the most heavily stringent, compliant system in North America. There's not any kind of regulation that could have prevented something like this from happening," she said in an interview on CBC News Network.
Chartier called the Wettlaufer case "an anomaly" and a tragic one.
"This is the first time in Canadian history somebody's ever done this in long-term care. It's devastating," she said.
Chartier said that while "nobody could have ever guessed that somebody would do this," there could be room for a review of how insulin is handled.
In long-term care homes there are some medications that require a protocol known as double-signing. When a nurse plans to administer those medications another nurse has to sign off. Insulin is not one of those drugs.
"Maybe this is something that we need to look at. We need to do a deep dive, and we need to determine, is insulin a drug that should be double-signed," said Chartier.
No word on inquiry
Another measure that could be considered: implementation of biometric technology that helps verify a patient is getting the correct dosage of the correct medication.
Some nursing homes also have so-called "granny cams" to monitor how staff are treating patients.
Family members of the victims, including Horvath, were at the courthouse to hear Wettlaufer's plea. (Peter Power/Canadian Press)
But Chartier said she doesn't think more regulations for long-term care homes are required.
Ontario's Health Minister Eric Hoskins was asked Thursday what actions the government is prepared to take in response to the Wettlaufer case.
Hoskins said he and Premier Kathleen Wynne have spoken in the past about their "openness to play whatever role" is needed on this matter, but that for now his focus is on the families and the devastating day they had in court.
Morris, from CARP, said it'll take more than an inquiry to help prevent another Wettlaufer; a cultural change is needed because many elderly people aren't treated with respect and dignity.
"We need to get rid of the toxic environment."