UPDATED: Records altered, care standards not met in death of Margaret Warholm

REGINA – The provincial ombudsman says there were several instances where the system failed a 74-year-old woman, who became malnourished, developed large bed sores and eventually died after living in a Regina care home.

In her report investigating Margaret Warholm’s treatment at Santa Maria Senior Citizens Home, Mary McFadyen offers 19 recommendations to help improve the facility’s care guidelines, reporting methods to the Ministry of Health, and communications with residents’ families.

“I’m not sure we have a good idea of what the needs are now. People are saying the needs of long term care residents have changed over the last 20 years,” McFadyen told reporters Wednesday morning. “Are we addressing that?”

Over a six-month period in 2012, Warholm lost 41 per cent of her body weight. She also suffered from bed sores and fell while being improperly lifted by care aides in August 2013.

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In the days that followed the fall, McFadyen found Santa Maria staff had edited some details of the incident to downplay it and changed Warholm’s care needs to suggest she was able to assist herself in dressing and eating when she couldn’t.

“I would make sure I asked a lot of questions if I put somebody in a long term care home.”

The ombudsman report says there was a lack of transparency and communication between the home and Warholm’s family.

“People truly understand accidents happen,” McFadyen said. “What we found was people just did not want to be lied to. So if their mother actually fell, they want to know what happened.”

Warholm’s condition deteriorated rapidly before her death in October 2013. Her family went public with the story in November 2014, demanding improved care standards.

‘Systen under strain’

McFadyen says many provincial and Santa Maria policies were not followed, including the way Warholm’s bed sores were managed and keeping up with her nutritional needs.

Her report also found the Ministry of Health and Regina Qu’Appelle Health Region are not properly monitoring whether their own guidelines are being met, such as requirements that residents “should be clean and have nice skin.”

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“Maybe it’s obvious, but it was not being done,” McFadyen said.

Margaret Warholm was suffering from a large bed sore when she was admitted to hospital in October 2013.
Margaret Warholm was suffering from a large bed sore when she was admitted to hospital in October 2013. Supplied / Warholm family

Since the investigation began in November 2014, the ombudsman received 89 complaints about long term care across Saskatchewan.

McFadyen says it became evident the province’s seniors care system is under strain, with possible changes needed to staffing levels and a recommendation that the government develop a long-term care strategy to address some of the recent issues.

“It’s systemic in the fact we’ve seen the same type of complaints from all over the province. So it’s not just an issue at one health region or at one long term care home,” McFadyen said.

Family closure

Leanna Macfarlane, Warholm’s daughter-in-law, says the ombudsman report brings a level of closure to the family.

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They spent several months going through paperwork and interviews with McFadyen’s office; Macfarlane was surprised to learn hear discrepancies between their experiences and what Santa Maria staff relayed to the ombudsman.

“Right from the get-go, there was cover-up after cover-up,” she said. “That’s what frustrated us.”

Margaret Warholm’s family says the ombudsman report brings a level of closure to the family. Kael Donnelly / Global News

Macfarlane hopes her family’s experience has helped others in the future.

“It made Saskatchewan open up their eyes as to what is needed when it comes to long term care.”

Government response

Warholm’s story is one of several told at the Saskatchewan legislature over the last year, leading to questions about whether there’s a crisis in seniors care.

Opposition NDP leader Cam Broten has repeatedly called for legislated minimum standards in care homes, which would set staffing ratios and care hours at a fixed number.

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During Wednesday’s question period, Broten repeatedly said the government has downplayed seniors care issues over the last year.

READ MORE: Seniors care crisis? Sask. health policy analyst weighs in

Health Minister Dustin Duncan responded to the recommendations, saying all will be implemented by the government.

He also agreed the process for ensuring long term care homes meet guidelines needs to be strengthened, along with greater ability for families to come forward and share concerns about care of their loved ones.

“That’s something we’re going to have to work at very hard and it’s going to take some time because, in any organization, culture doesn’t change overnight,” Duncan said.

Since fall 2014, Santa Maria says it has introduced 25 changes “that will improve quality, safety and care for every resident.”

“Every one of our residents deserves compassionate, respectful care in a community that puts their safety first,”executive director John Kelly said in a news release.

The ombudsman will follow up on her recommendations by the end of 2015.


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