Staff at an Okanagan dementia care facility failed to notify RCMP of a violent patient-on-patient assault and inaccurately documented the incident, according to an internal investigation completed by the health authority.
Marilyn (Lynn) Claire Anderson, 83, died on Dec. 13, 2018, 13 days after she was attacked by another patient at the Orchard Haven long-term care facility in Keremeos, B.C.
Her son, Alan Anderson, said he was initially notified by staff on Nov. 30 that his mother was being medically treated at an on-site clinic following an unwitnessed fall.
He wasn’t informed of the severity of her injuries until hours later, when Lynn was transferred to Penticton Regional Hospital (PRH) and the couple was contacted by hospital staff.
Lynn had sustained a fractured hip, elbow, ribs and skull, along with a black eye.
“One eye was black, swollen shut, the size of a golf ball sticking out of her head where the fracture was,” said Lynn’s daughter-in-law Sharleen Anderson. “How can you think, ‘Oh, she’s just going as a precautionary scan, she will be back home tonight’?”
The Andersons weren’t informed Lynn’s fall was the result of an assault until the following day when they arrived at the hospital. They also learned staff failed to contact police.
They notified RCMP of the attack themselves two days after the incident.
Upset with the lack of information initially provided by Orchard Haven staff about the assault and the failure to inform authorities, the Andersons filed a complaint with the Patient Care Quality Office at the Interior Health Authority.
An internal review was conducted by patient safety investigator Sandra Psiurski. She determined that police should have been notified right away.
Psiurski said in her letter to Lynn Anderson’s family that the manager on call was not familiar with all of the residential care procedures that must be followed after an aggressive incident.
The RCMP should be notified of resident-to-resident aggression that involves significant injury and Anderson’s assault was a reportable incident, the letter stated.
“Thank you for advocating on behalf of your mother by notifying the RCMP. Please be aware that this manager is now aware of her oversight. As well, education on incident reporting and follow up will be provided to all on-call managers and facility managers,” the letter said.
Const. James Grandy said police did investigate, but charges were not recommended. The matter was forwarded to the BC Coroners Service, where the file remains open.
Psiurski also found that staff improperly classified the incident as an unwitnessed fall.
“It is unclear why staff did not correctly categorize the incident on the licensing report. Although a fall did occur at the time, we can only be certain that an assault took place after the fall, as this was witnessed by care staff. This incident should have been categorized as a physical assault,” she said.
Psiurski added that staff will be educated about how to accurately report licensing incidents and future reports will be reviewed and audited to ensure they are correctly completed.
The Interior Health investigation also determined the unit was properly staffed at the time, with one care aide and one licensed practical nurse (LPN) per 14 patients. However, the LPN was off the unit at the time of the assault completing administrative duties.
A care aide heard noise from the nursing station and immediately went to investigate, according to the letter.
She discovered Lynn Anderson on the floor and a co-resident was kicking her in the legs.
“As soon as the care staff arrived, she distracted the co-resident who was kicking Lynn and the co-resident began kicking at the care aide instead. The nurse arrived a few moments later to assist in deescalating the situation,” Psiurski said.
Sharleen Anderson says the lack of communication still hurts.
“I think one of the glaring things that really hurts is still we have not been contacted from Keremeos, we never were contacted from them, while she was in the hospital or after she passed, and I think just as a human being, you would reach out and give condolences, and that would have minimized the bitterness that we feel,” Sharleen said.
She also encourages family members of care home patients to communicate with each other about the care their loved ones are receiving.
“Interior Health neglected to communicate and ultimately the families need to be in contact with other family members, you need to build a network of support among the people because you are not going to get the facts from the staff,” she said.
Lynn was also the victim of resident-to-resident aggression on Aug. 7, 2018. Staff stated the dementia patient was pushed from a seated position to the floor by another resident.
While the Andersons said they are aware of additional staff training, education and oversight at the facility in the wake of the incident, it’s too late for their loved one.
“Our mother was just a peaceful, kind, loving lady. She didn’t deserve this tragedy. It’s been devastating that this happened to somebody and the fact that she was only there for seven months. My mother had two black eyes in her life, and they were both since she was in a care facility,” Alan Anderson said.