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Inadequate Care and Untrained Staff

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Devonshire Care Centre
1808 142 Street
Edmonton, AB
(780) 665-8050

There were countless incidents at the Devonshire Care Centre, where I believe the “medical care” provided to my friend Rita Vallentien’s, put her at risk. There were countless incidents where my friend’s basic needs were not met.

Therefore I am writing this letter in an effort to affect change in extended care homes. Rita Vallentien was at Devonshire Extended Care from Mid June to the End of September when I removed her from this facility. It has been some time since Rita was in this facility, but what occurred to Rita needs to be told.

Devonshire

The issue was inadequate and untrained staff. There were a few staff members who were very good at their work, but the majority did not have the level of training needed to deal with a resident at the level of care Rita required. I believe the majority of these staff worked to the best of their ability. I also have seen a number of staff rush their care and spent time visiting at the desk.

I believe there is lack of policy and procedure. If the policies are in place for appropriate care, then the follow up was inadequate. I say this because the care was inadequate to the point of serious risk for Rita.

I have enclosed a list of incidents I have seen. Considering that I only visited the centre and was not there 24 hours a day, the number of incidents I witnessed was frightening. I also know that many of these incidents have not been documented because the underlying fear of losing a job has kept staff from reporting issues.

Based on a conversation with upper management my opinion is, fear of litigation has kept the management from admitting the issues and finding ways to resolve them versus finding ways to cover them up.

I wrote a letter regarding my concerns to the upper management. This letter was shown at a report session and the staff where told to improve. My question is, How can the staff improve:

  1. if they do not have the training to improve?
  2. if they do not have the processes and procedures that ensure needs are met?
  3. if they do not know what to do with a person with specific medical needs?
  4. if they do not feel safe reporting incidents which require investigation or immediate attention.

In my opinion, this centre was in crisis when Rita was there. I consider the Devonshire Extended Care to be an unsafe facility for residents who require a higher level of care. A resident who is unable to feed, toilet, move around or speak for themselves is at risk in this centre.

In my opinion, they needed help to improve the care for their residents. I do not believe they will reach out to other sites with years of experience or to the regulators who can help them. I believe Devonshire Extended Care Centre needs someone to go in who will investigate, evaluate and recommend the changes so the residents at the centre receive the care they truly deserve. Perhaps some changes have been made but I believe this centre will need to be monitored for some time before they will improve sufficiently.

Upon moving Rita to St Joseph’s auxiliary hospital, I saw a completely different level of care. There were clear guidelines and expectations. Policies where established. The staff worked the entire time they where on duty (excluding brake times). The staff had full time positions. The entire group worked as a team. They where concerned with her pain level and took measures to be sure she had minimal pain. Her hygiene was great. They changed her diaper often. They positioned her regularly. They fed her with a small spoon and asked family or friends to take a class on how to feed her properly. They communicated with her friends/ guardians what her day was like. These are simple steps, yet so important. How can one facility be so entirely different from another? How can we allow this to happen to our seniors? These sites need to be monitored.

I realize the staffing levels are different. I believe Rita should never have been admitted to the Devonshire. They said they could care for her when they clearly could not. She needed to be in a facility that was capable to care for her. This is why I moved her.

I sincerely hope that this letter will make someone stand up and take notice. We all have the possibility of being in such a facility in our future. We can make the life of the current and future resident’s safe if we take action now.

Sincerely,

Shirley Lumme

Attached: List of issues

What I hoped for Rita was the following:

  • She was a woman proud of her appearance: I expected her to have basic hygiene. This did not occur.
  • I wanted her medical needs to be looked after: I did not expect to have to constantly watch that this was done.
  • I wanted her to be comfortable with minimal pain: There where incidents due to staff, where her pain was actually increased.

It was disturbing to see such substandard care. It was clear to me this centre was incapable of caring for someone with Rita’s level of needs. I knew I had to get her out of there before they caused her death. I realize she had little time left but I wanted her to live it safely and with dignity.

I often thought of those whose families are not able to monitor their loved ones. I say other incidents with other patients and spoke with family members who had issues as well. I am truly saddened that our seniors have been treated this way.

This is an incomplete list of separate incidents and concerns which occurred while Rita Vallentien was at the Devonshire Nursing Home. Only those incidents written down at the time are included.

  • The time frame required to set up a care plan for Rita was six weeks. I believe each patient needs to be assessed and a care plan established in the first week. Staff needs to know what the requirements for each patient is. This plan needs to be known by all staff, including the PCA’s.
  • A special sling was used to help with pain. It was not used correctly causing more discomfort. Even when a poster was placed on the wall, the staff did not use it correctly. The end result was the sling was ignored.
  • Something was wrong with the wheelchair. I am had to report it. The staff is there all day and they did not report. I feel they should take the time to report such an obvious problem.
  • From June to September, Rita went from sitting up in her wheelchair for hours to unable to hold herself up. She was left in the bed for days.
  • I was asked to leave while Rita was moved from; her wheelchair to her bed. This was a new policy I was not told about. When I refused the head PCA was asked to be in the room.
  • When they moved her they used a sling that pulls her up under her arms. Rita had a drop shoulder which was painful. This type of sling should not have been used on her. When I told the OT that they where using this sling, she was surprised, and said she would check into it. I am not a nurse or a PCA but it was obvious to me this sling was inappropriate and causing pain. Rita did not want to be transferred and this is when I realized why.
  • There was limited concern with positioning Rita. I rarely saw staff change her positioning. She often had her arms laying down or falling out of the bed. This caused water pooling, which is painful.
  • I came in one time and found Rita half way out of bed. She was unable to move her one side. It would have taken her a long time to move that far. It was obvious no one had looked in on her for some time.
  • I was asked to buy a bed alarm. It was used once and disappeared within two weeks of purchase.
  • When Rita was being changed, I observed a PCA pull the pillow from under Rita’s paralyzed arm and just let it drop. She should have placed the arm on the bed. This to me is common sense.
  • There where many occasions when the ward Rita was on had only one PCA to attend to all the patients. The person on had to ask an attendant from another ward to assist in moving the clients.

Clysis

When Rita was returned from emergency two PCA’s moved her while I was there. In the process her site was pulled out. They should be aware of the site and take precautions not to damage it.

I checked Rita’s site and it was red with redness around it. I told the nurse. She changed the site. It was placed in Rita’s leg. 10 minutes later I checked again and there was a large bubble on her leg. I found the nurse; she stopped the flow and said she would change the site. These sites need to be observed after changing to be sure this does not occur.

Devonshire

Rita once showed me her leg. The tape had come off and the needle was poking into her leg. She was in pain.

The clysis had been in her abdominal region for a couple of weeks. Rita had bruising due to this. There was definitely discomfort. The staff was not rotating the sites.

Clysis bag ran out resulting in air in tubing. Nurse comes to change bag and takes off the tubing from clysis needle. She then realizes she has no where to put it so it remains sterile. She reinserts tubing into the clysis needle and then opens bag. Now she can not get tubing off the needle. Rita is moaning and in obvious discomfort as she tries to remove the tubing. Another nurse comes in and tries. They eventually use a needle with a small gage syringe to remove the air form the tubing. The plunger comes out and is contaminated. The nurse continues to use the syringe. This was not proper sterile procedure.

The night nurse came in to check Rita’s site. It was extremely red and the date on the site was past due for changing. This was the site hooked to the IV bag. We found another site on her body. The day nurse had not removed the old site or switched the IV bag.

Rita was sent to emergency without my permission. I was called and told she was going at 11:30 pm. When I was told that no one would be going with her, I was concerned. The facility assured me the emergency would be informed about Rita. I left work to meet her at the hospital. No one knew anything about why she was there and she could not talk. Someone needed to be there. This was not an emergency; tests needed to be done to access her status. There could have been an option given to me. More importantly, a staff member should have been sent with her.

Once when I called Rita’s companion, I heard Rita shrieking in pain. I called the nursing station and asked them to give her an injection of pain medication. They said they had no order from the doctor. I knew it was there but they would not look. In the same incident the day nurse asked Rita if she was in pain. First Rita did not speak; second Rita was moaning and crying. This was a cruel and ridicules question. The companion told me she went to the desk several times and the nurse she spoke to said he needed to finish his paper work. The pain was caused by the physiotherapy. I had no idea of the horrible pain she was experiencing. The facility she was transferred to said their policy is not to cause pain for the patient.

General

Devonshire

Hygiene was not good. Rita would not have her teeth brushed or her hair combed. She often wore the same clothes for days until I asked the PCA to put them in the wash.

I received numerous phone calls from Rita’s other friends regarding what she needed. I.e. she needs slippers, she needs pants, she needs toothpaste etc. etc. I was asked almost daily in the first few weeks for items she needed. As discussed at one meeting a list of items required when in the facility would stop this issue. It could include Personal items, clothing etc that she needed and that could make the work of the attendants easier. These should be specified to the level of care the resident needs. (I.e. loose clothing for stroke residents, type of slippers, type of bras and under clothes, pajamas). Most caregivers would appreciate guidance in these matters. I know I would have appreciated knowing what would make it easier for the PCA”S to dress Rita.

I observed PCA’s feeding patients. It broke my heart when I saw them shoveling in food with a big spoon. The faster they could get the patients done the better. There was no patience to allow for them to eat at a normal pace. Scoop shovel, scoop shovel without letting them finish their first mouth full. I saw one women tell the PCA to stop. I was proud of her. Some patients went without when staff was watching their intake.

Policies where made up as they went. I would think a centre that was in business this long would have policies in place. There should be a set of standard policies for all centres.

Rita had a companion who worked at the centre. For a time frame it was acceptable for her to do both. This companion was shared between two patients. One of the nurses came to me to “tell” me our companion was visiting the other patient when she should be with Rita. I told him we had an arrangement for this. Next thing I know a new policy was established that they could not work there if they where a companion. They said it would be grandfathered for previous situations, but where strongly encouraged to cease being a companion. This was an unnecessary stress put on all of us by this centre. There main concern was litigation and not the patient’s best interest. If they really cared about the patients they would not ask the caregivers or the patient to try to establish a new relationship with a new companion. This takes time and trust.

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