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Sustained Elder Abuse Unidentified Violence and Neglect

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Disturbing incidents and events that occurred during Mom’s stay at the Dr. Gerald Zetter Care Centre that were not addressed or dealt with in a fitting manner when family requested an explanation. Mom was at the Gerald Zetter Care Centre from July 2000 to Dec. 2001.

The attendant then grabbed my mom by the forearm and, by pulling her by the arm, rolled her on her side.

  1. A bruise on the side of her mouth that could not be explained.
  2. Bruised and badly swollen fingers on her left hand. She was taken to the Royal Alex Hospital for x-rays. Mom told us she had a fight with a care giver, but we could not get any explanation from the staff.
  3. Mom had fallen out of bed during the night and could not get any ones attention until they found her on the floor at shift change in the morning. The staff did not notify the family about the incident. I requested an explanation as to when staff last saw Mom in bed and what condition Mom was in when they last saw her. We never did receive any explanation. I also demanded to know why they did not notify the family about the incident. They then told me that they did. When questioned who they notified I was told that they called ======, which was not true because they were talking with ====== (they did not realize that) and I did not receive a call. We also had call display so we would have known if they had called.
  4. Mom was once placed in a wheel chair after breakfast. I was with Mom during lunch and Mom wanted to go to bed after lunch. I told a staff member that Mom wished to be put in bed and was promised that this would be done right after they finished with lunch. My brother was there during supper and Mom was still in the wheel chair. It was about 6 o’clock when he asked a care giver if they could put Mom in bed. He was told she would have to wait till after 7 o’clock because they were now going for supper. This was about 5 hours after she first asked to be put to bed.
  5. Mom has now been put on oxygen. About a month had passed and I noticed that the air intake filter was very dirty so I asked a care giver (Mike). Who was responsible for cleaning the filter? I was then told to clean it if I liked to.
  6. Mom was also totally bedridden and had developed a very bad pressure sore. There were times when Mom had soiled herself and was left to lay in that for a long time. The dressing on her pressure sore was not changed regularly and there were times when we found there was no dressing at all causing infections.
  7. While being totally bedridden there were times when Mom had bruised toes. NO explanation for that.
  8. Mom was terrified about going for a bath.
  9. Mom’s call button was very seldom within her reach.

Letter

Joanne Flamand
Client Service Manager
Dr. Gerald Zetter Care Centre
9649 71 Ave
Edmonton, AB T6E 5J2

January 22, 2002

Dear Ms. Flamand:

I’m hoping you could address some concerns I have regarding events which happened during the last few days of my Mother’s 17 month stay at your facility. We’ve met previously on some of these issues, but I’ve felt these meetings were not very productive, partly because I find it difficult and upsetting to talk about these issues. I’m writing this letter to better focus my thoughts and give you a clearer picture of my concerns.

I wish to bring to your attention three specific issues (though I could list more) that I feel were indicative of the treatment given to my Mother as well as the handling afforded to our family during her stay. I think they also illustrate some of the frustration we felt in dealing with members of your staff on these matters.

#1 December 28, 2001

Family members were in my Mother’s room. At about 7:00 pm a caregiver entered the room and I asked how long my Mother had been in the position she was in because she looked uncomfortable. We were told she was in that position since 4:00 pm and that they would soon turn her. He left to get someone to help him turn her, when he returned he changed his story, saying my Mother had been turned at 5:30. My brother-in-law mentioned to the caregiver that family members were in the room at that time and that no such repositioning occurred. The caregiver then said it may have been done at 6:30. This was not the case as family had been in the room since 4:30 that day.

We found this incident to be upsetting for two reasons: 1) staff did not seem to us to be sufficiently aware or sensitive to the scheduling of regular events (her repositioning, but also pain-control); 2) the staff communicated information poorly to the family, sometimes seeming to assert things to us that frankly just weren’t true. Over time, those kinds of false statements eroded our trust in the facility.

#2 December 29, 2001

I was present in the room when an attendant was changing my Mother’s dressing. While the attendant was dealing with my mom I asked if the doctor had been in (my sister had been told on December 25 that your staff would be contacting the doctor). The attendant told me that the doctor did not see my mother in person, but that the doctor was contacted and gave instructions via phone. When asked what those instructions were I was told she would have to check her chart. We went home before we got a response but were called back by the nursing home because of my mother’s worsening condition. We arrived at the hospital about an hour-and-a-half later. At that time we asked to see her chart to see what the doctor had ordered. There was no mention of a call to the doctor on the chart. When asked about this, the attendant then denied ever telling us that the doctor had been contacted. The issue here is not whether the doctor was or was not contacted, but the manner in which information was given to us. It seems as though information was given ‘off-the-cuff’ and without regard to the actual facts. We found this to happen frequently, staff would often give quick answers rather than correct ones. This made it hard for us to deal reasonably with events and staff and led to a needlessly frustrating experience.

#3 December 29, 2001

Even more upsetting was this: an attendant was finishing with changing my mom’s dressing. I asked if she could be put on her side because she had been on her back for some time. The attendant then grabbed my mom by the forearm and, by pulling her by the arm, rolled her on her side. I am left to speculate whether this type of treatment could explain the bruises that my mother had on her arms for months, the numerous skin breaks on her upper arms and hands, and why she frequently complained of very sore arms (find enclosed photos of her arms, taken December 23, 2001). Is this rollover procedure considered standard or acceptable practice? If so, I would like it noted that I find it an unnecessarily rough way to treat a frail, elderly patient.

As an aside, you had called an investigation into a skin break that occurred on the back of her hand (December 18, 2001). I’d ask you please mail the results of this investigation to me.

I would like to say that we also ran into some devoted, sincere, and caring individuals on your staff. They should be complimented.

That doesn’t change our strong feeling that there are problems that you might want to address, namely the regular administration of some procedures that directly impact the patient’s level of comfort (for example, the schedule of patient repositioning and administration of meds (as discussed at previous meetings) as well as the manner in which information was communicated to the family. Miscommunications made it hard to feel certain that the care our mother was supposed to receive was being administered. That’s a terrible feeling to have.

I write this letter trying to help you better understand our experience. Please take this in the constructive manner in which it is offered. Feel free to contact us should you require addition information or detail.

I would appreciate if you could reply to this letter in writing.

Sincerely,

Name Removed

Response

April 12, 2002

Name Removed

Thank-you for you letter dated January 22, 2002, and this time you took to meet with me on January 23, 2002. It is unfortunate that the experience and care received by your mother did not meet your expectations.

I have been off work for a period of time, and have been unable to respond to your letter, and do apologize for that.

We have taken all of your observations seriously and have completed an investigation surrounding your concerns expressed about your mother’s care while a resident here. It is our commitment to ensure that resident’s receive quality care at the Dr. Gerald Zetter Care Centre. We will take any necessary steps to ensure that your observations regarding this situation are addressed and will make the necessary improvements.

I hope this will help you bring closure to these concerns, and again I thank you for bringing your concerns to my attention.

If you have any questions, you can reach me at 431-3602.

Sincerely,

Joanne Flamand, RN
Client Services Manager

The Good Samaritan Society P.O. Box 8190, Edmonton, AB T6H 5A2
Ph: (780) 431-3600 email: goodsaminfo@gss.org website: www.gss.org

Response

Queenie Choo,
Director of Operations
Dr. Gerald Zetter Care Centre
9649 71 Ave
Edmonton, AB T6E 5J2

May 15, 2002

Dear Ms. Choo:

You came across as being very sincere when you called April 26, 2002 and said you were going to review the staff and operation of the Zetter Care Centre and make the necessary adjustments to make it a facility that will provide compassionate care with respect and dignity to its residents. To help your investigation, I believe you should be familiar with some of the events and incidents that transpired during Mom’s stay at the Centre.

I realize that it’s not possible to change the past but I wish to list some of the events that happened and which we requested explanations for at the time but never received to this day.

I hope this helps you better understand why we feel frustrated, bitter, and mistreated by the facility.

Incidents

  1. Bruise on the right side of her mouth that wasn’t reported by the staff
  2. A sprained finger on her left hand that Mom said resulted from a fight with a care giver. We could not get any information from any staff on this.
  3. Bruised toes when she was totally bed ridden. There was no explanation.
  4. Bruises and skin breaks on her arms.
  5. When Mom was found on the floor one morning we could never get any information as to when someone saw her in bed last, what condition she was in, and why they did not notify the family of the incident but recorded that they did so.

I also want to outline what we felt was poor and disrespectful attitude on the part of some of your staff.

  1. We always asked the staff that they should tell Mom what they were going to do before they did it as she was very fearful and hard of hearing. Some staff repeatedly did not do this. On one occasion I asked Mike to reposition Mom. He grabbed the soaker and in one motion turned her quickly, frightening her. He explained to my Mom (after the fact) what it was he had done. I suggested it would be more helpful if he would explain the procedure before he did it. His reply was, ‘I just did’.
  2. Mom was put on oxygen and I noticed the filter on the unit had not been cleaned for about a month and seemed very dirty. I asked Mike, ‘who was responsible for cleaning the filter?’ His response was, ‘Well, clean it if you like.’
  3. We also witnessed a few of your staff handle Mom very roughly on several occasions.
  4. I found it very disturbing to see the attitude and disrespect towards patients displayed by Karen.
  5. The incident with Fran on December 29, 2001 was very disturbing (grabbing Mom by the forearms to turn her, as outlined in previous correspondence)
  6. Also when we met with Joanne on January 23, 2001 and asked for the results of the investigation into the skin break incident of December 18, 2001. Her reply was that she had no report because she could not get a straight answer from anyone on this matter (which is exactly what we dealt with every time there was an incident or when we had a concern).
  7. I had outlined several concerns in a letter dated January 22, 2001. Joanne promised a written response to my concerns. These have yet to be addressed directly, despite repeated correspondence about the issue. Please fulfill this promise and answer my concerns.

I hope you seriously investigate these incidents and work to correct them. I appreciate your attention in these matters.

Sincerely,

Name Removed

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