CALGARY – Alberta Health Services has released their review of care policies at a local senior’s centre after the death of one of their residents.
75-year-old Wyonne Somers died at the McKenzie Town Care Centre. She was battling sepsis, an infection of the bloodstream. Her family says Somers developed a severe urinary infection and leg sores, because her underwear was not changed frequently enough
Alberta Heath Services says they received several complaints about the facility, and their review found several areas for improvement.
A spokesperson for McKenzie Towne Care Centre says they have implemented several changes in response to the review.
“All continuing care residents, including those at McKenzie Towne Care Centre, deserve care in an appropriate, timely and responsive fashion,” said Brenda Huband, Interim President and CEO for Zone and Health Operations of AHS.
Some of the changes at the facility include the implementation of a new computer program to track wounds, and new skin care protocol.
In addition, AHS wound specialists will continue to visit the site every week.
CLICK HERE to read the complete review, or see highlights below:
Issues identified:
Several issues related to resident care were identified following the AH audit, the AHS audit, the Protection of Person in Care reports, and a full site review of skin and wound care at the McKenzie Towne Care Centre, owned and operated by Revera. Issues included:
- Gaps were found in resident documentation.
- Wound care practices were not being followed adequately in some cases.
- Storage practices for equipment and medical supplies were not being followed adequately in some areas.
- Management of aggressive and violent behaviour of residents.
Actions taken to date:
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All aspects of care pursuant to the Continuing Care Health Service standards at
Mackenzie Towne Care Centre have been reviewed and all recommendations are being implemented.
These include:
Audits and Action Plan:
- An action plan to address quality of care issues at McKenzie Towne Care Centre (MTCC) was approved by Alberta Health in early December 2013.
- Alberta Health conducted a CCHSS site audit on Dec. 5, 2013; AHS conducted an independent CCHSS site audit on Dec. 6, 2013. McKenzie Towne Care Centre and AHS created an agreed upon action plan to address the audit recommendations on Dec. 11, 2013.
- On Dec. 27, 2013, AHS reviewed all recent quality indicator documents (Protection for Person in Care (PPIC) reports, Patient Concerns reports, and Reportable Incidents), and found these areas to be within the acceptable range for continuing care. Resident
concerns logs and documentation, including reportable incidents between April 1, 2011, and May 31, 2013, were reviewed for all Revera Long Term Care sites in Alberta by the AHS. This review was complete on Dec. 18, 2013, and AHS confirms that all resident concerns were addressed within a reasonable timeframe.
Quality of Care Oversight at McKenzie Towne Care Centre:
- At the request of Alberta Health, an experienced AHS staff member was assigned to assist at the site on a daily basis until further notice from Dec. 3, 2013.The AHS lead is temporarily based at the site, and attends morning and afternoon daily clinical meetings.
- Weekly meetings are currently scheduled with AHS and the McKenzie Towne Care Centre team to review the action plan. This first meeting took place on Dec. 12, 2013, and these meetings continue weekly to date. The action plan is updated and submitted weekly to AHS senior leadership and Alberta Health.
- AHS has been directed by Alberta Health to make a determination of when the action plan has been fully addressed at the site. There was a meeting held earlier this week to discuss ongoing sustainability and sign-off process and approach. As a result, AHS onsite presence will continue until Jan. 31, 2014.
- Plan is for a follow-up targeted AHS’ CCHSS audit in the next few months to address and assess compliance with standards, e.g. care plans and wound care.
Wound Care at MTCC:
- AHS undertook an in-depth review of all wound care cases and practices, involving AHS skin and wound specialists. That review is complete and recommendations are being implemented at the site.
- the implementation of a computer-based wound care assessment, treatment and documentation system;
- establishment of a formal skin care protocol, and the standardization of a wound assessment and measurement tool.
- This review was complete on Dec. 12, 2013, and AHS met with MTCC on that date to share these recommendations and formulate an action plan, including weekly follow-up until all issues have been resolved.
- Weekly Wound Care rounds have been established with the AHS Wound Care Consultant with the first regular visit on Dec. 27, 2013.
- AHS took this opportunity to review its own internal processes for Consultant Specialist referrals (e.g. wound care). As a result, AHS has developed a more formal process to provide expert health care consultant visits at contracted provider sites. This revised process was implemented across the Calgary Zone on Jan. 7, 2014.
Care Plans and Resident Assessment Instrument (RAI) Processes:
- AHS is conducting a quality review of the Resident Assessment Instrument (RAI) process and to ensure RAI outputs are being integrated in care planning and care delivery. According to best practice, 10% (15 charts) have been reviewed in detail, completed on Dec. 19, 2013. The report on this review will be submitted to AHS, as per the normal process, in the week of Jan. 13, 2014.
- AHS is supporting continued staff education sessions at McKenzie Towne Care Centre to reinforce the expectations of the use and update of RAI assessments and the requirements of care plan documentation. All McKenzie Towne Care Centre resident care plans are scheduled to be fully updated by McKenzie Towne Care Centre by the end of March 2014. Fifty care plan updates will be complete by the end of January 2014, and an additional 100 by the end of March 2014. The process is currently on track.
- McKenzie Towne Care Centre is in the process of reviewing processes for ongoing engagement with and support for families. Families are engaged with the site and have input to the developed plan of care. There is a Resident Family Council and a process for resident complaints. This requirement was met in the CCHSS audits.
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