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Deadly Neglect at the Devonshire Care Centre

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1808 142 Street, Edmonton, Alberta

I brought my 92-year-old, paraplegic mother to Canada from the U.S. in late April of 2005 to provide much-needed supervised care for her. After a three week stay with me, I arranged to place her in the Devonshire Care Centre because Mom’s care needs are very high and I knew I could not care for her on my own. At that time, the Devonshire was the only continuing care place that we could find that would accept citizens from other countries. Fortunately, we were able to pay the $5,750 the Devonshire charges for a “private” room. I assumed that for that price, her care would be good.

It was not good, in my opinion it didn’t even reach the level of marginal. As it turned out I had to go in every single day for six months to just protect my mother and make sure she was even minimally cared for. But although I was disturbed by what I saw there, it certainly gave me a chance to see what was really happening.

To begin with, I was appalled to find that her bathroom floor was not kept clean; it had a permanent layer of grime that had more or less annealed to the floor. With effort, it could be scraped up with a fingernail. I also noticed that the commode was not always in pristine condition. And the bedroom smelled like urine, until I finally spoke up. These were the least of my concerns, however.

Although I could see that most of them were doing their best, many of the employees at that facility did not appear to be properly trained, On one unforgettable occasion, a new male employee attempted to transfer my mother from chair to bed without help. This was not supposed to be done in my mother’s case, so either he had not read the instructions written in large letters above her bed, or there were no other personnel available to assist him. He was using the sling incorrectly and barely managed to get her onto the bed without dropping her. This was observed by a third party, because, fortunately, a good friend of mine chose that moment to walk in to pay a visit. She told me later that he was also hurting my mother as he did the transfer and that she had been crying out in pain. Seeing all this, my friend immediately went in search of a nurse and asked her to give some instruction to the man so that this would not happen again. My mother, who is very frail and osteoporotic, would have suffered significant injury if she had been dropped, which could easily have happened. Later, my friend went with me to the manager’s office to let them know what had happened and, to my knowledge, this particular incident did not occur again. But many other problems arose on a daily basis and included such matters as disregarding repeated food requests (it was purportedly their policy to honor food requirements), finding soiled underwear sitting on the bedside table next to the snacks, a broken personal pager, a pager lost by staff, or a pager placed too far away for my mother to reach, leaving my mother(who has serious issues with pain) too long in her chair, or simply leaving her in bed if I did not happen to be there. Because I went in every day, I know lot of problems were avoided, which. of course, is precisely why I came in. Devonshire

One of the female care attendants, a very conscientious and caring lady (who no longer works there) came to me because she was concerned about the same male employee who had made a risky chair to bed transfer with my mother. He was apparently placing my mother in her bed in the evening in such a way that it would jar my mother’s indwelling catheter loose. According to this lady, he was in the habit of jamming the tubing back into my mother’s body. Horrified, I reported the incident, and was relieved when two new attendants finally came on duty for a few weeks. But I do not know if anything was ever done about the incident with the catheter. I occasionally saw blood in her urine bag and toward the end of her stay there she had a fairly serious bladder infection. I still wonder about why that happened, and of course inquired. But no one, including the nurses, seemed to be very concerned. By then, I was seriously frightened and had even been warned by the female care attendant who reported the catheter incident that because of her relative helplessness, my mother wasn’t really safe there. She had seen other things happening that worried her, and was unable to do much about it in her position, but she did what she could to warn me and, I am sure, other families. After six months at the Devonshire, I couldn’t get my mom out of there fast enough.

In addition to what looked very much like poor supervision and apparently inadequate training, there was the serious problem of too few staff. There always appeared to be very few, if any, employees on duty anywhere at the Devonshire. I saw more cases of oversight there than I could ever keep track of. It was one of the saddest places I’ve ever been, with elders in wheelchairs sitting for hours in hallways or lying alone in beds, sometimes weeping from loneliness and often waiting for far too long to get help with toileting or a change in underwear. I could see that most of the care attendants tried their best, but it seemed pretty clear that supervision by management must be very slack indeed. I undoubtedly observed a lot that might otherwise go unnoticed because I was there every single day. One thing I quickly learned was that it did little good to call on the buzzer because the nurses were often nowhere to be found and care attendants were usually elsewhere as well. I knew from my own observation that sometimes there were no attendants at all on Mom’s floor, although I had been told by the CEO there that the ratio of care attendant to resident was quite good. I saw nothing at all to bear that claim out. In fact, the Devonshire was one of the emptiest looking institutional places I have ever seen.

I made friends with many of the residents. One lady my own mother’s age, liked to visit with us and chat. She was quite lonely and told us that she was originally from Ireland. I would often go back with her to her room and help her smooth out her bed covers which were usually rumpled. I did this at her request and because she really enjoyed that little attention, and I enjoyed being able to provide it. One day, however, I came to the Devonshire and found her in what appeared to be a very medicated condition, slumped over in her wheelchair. I was concerned and asked a staff member what had happened and was told that medication was given because she was “too much trouble to bother with.” I seem to recall that she also mentioned that there were simply not enough people to deal with her. I was stunned, but could get no further information because I was not family and could not get the family’s address or phone number. I didn’t even know their name except that it differed from the lady’s. I recall seeing the head of nursing standing over her a few days later and saying “she is way, way too medicated.” I was very relieved to hear this, hoping that the medication would now be changed. But the following week, she was still almost comatose in appearance and still bent over in her chair, only now there was a large, very nasty looking black bruise on one side of her face. Alarmed, I asked staff if they had notified her family about the bruise and was told yes, they had done that. I was not able to learn what caused the bruise. A short while later she died. I tried again, with no luck, to locate her family, this time through the funeral home to tell family what I had seen and heard, but it was the funeral home’s policy not to give out such information. I also reported it locally to those who take an interest in elder care. I still don’t really know what the cause of death was, but I learned from the obituary that cremation had taken place almost instantly. I am haunted by the memory of that delightful lady who was “too much trouble to bother with.” It would be good to have a law in place preventing hurried cremations under such circumstances.

Not surprisingly, there were generally too few attendants in the Devonshire’s dining room when I was there at mealtime, and on a few occasions there were none at all. Mealtime was generally a cold and silent experience, with food being set down quickly. Once, I saw a Jewish resident being served ham; of course he did not eat the dinner, and was left with almost nothing to eat. Since that was the only food being served, I went to the fridge and brought him a home made muffin from a batch I had brought in for Mom and was thanked with great courtesy. It was all he had to eat that evening. I saw a lot of residents wheeled away from what appeared to be full plates day after day. And, probably because the place was understaffed, the residents who were actually fed by attendants were sometimes given overlarge spoonfuls of food that were hurriedly jammed into their mouths. I saw one lady nearly choke when this happened and was delighted when she sputtered and said, “dammit, I don’t want anymore.”. My mother, fortunately, is able to feed herself, although I used to come in and help her, and sometimes help others as well. I will stress that the attendants who were present, were, usually pleasant to the residents and, aside from the large spoonfuls, tried to be as helpful as they could. But they were overworked because there just weren’t enough of them.

One good friend of ours refused to visit during meals at all after just one visit at mealtime. On the day of her visit, she observed the residents being served huge, tough, overcooked pork sausages at lunch. Most of the residents at that centre are frail and seem to have dementia, and I doubt they could have even cut the sausages up for themselve, much less eat or digest them. As it was, most of them were given no assistance at all because there were not enough care attendants available and so most were not able to even attempt to eat the sausages. My friend was understandably angered by the neglect. Later on, I observed this happening again, and again watched residents being rolled away from uneaten meals. It does not surprise me at all that this care centre has been in the news because of one resident who died partly as a result of malnutrition. The surprising thing is that it has only come to light in one instance. Personally, I brought in extra food for my Mom to make sure she got enough fresh foods and protein.

I eventually located a very fine group home facility Edmonton, Mirkacare Services, who were able to make room for my mother and have provided her with excellent care since last October. I moved my mother in only a few days after contacting the owners. Although I still visit my Mom frequently, I no longer have to drive in every single day just to keep her safe and ensure that she is being cared for. I am very grateful to have found this home who, incidentally, provide a hundred times the care at a lower cost. It is wonderful these days to no longer have to make a panic-stricken search for nonexistent attendants. It is wonderful to know that the people looking after my Mom are well trained, compassionate and always immediately available. And it is a blessing that we have found the means to cover the cost. But I think about the many elders who do not have these benefits.

Sheila Cox

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