When June Bendell died at the Orchard Villa nursing home in Pickering, Ont., three weeks ago, her children were told she had choked while she was being fed a nutritional drink.
The death was deemed accidental.
So they were surprised to hear what appeared to be a different version of events from the Canadian Armed Forces.
A report released on Tuesday said military personnel sent to Orchard Villa to control a COVID-19 outbreak had found that staff were not always sitting residents upright before feeding them.
The military report went on to say the high risk practice may have contributed to the death of a resident who had choked when a nursing home worker fed her “while supine.”
The resident who died was not identified, but Fred Bendell said he is convinced the report was referring to the death of his mother at Orchard Villa on May 8.
“I couldn’t believe it,” he said.
The woman’s daughter Pamela Bendell also said she was certain. She said she had already been told the military was in the room when it happened.
Their mother was not supposed to be fed without being elevated, they said.
“So now we heard she was lying on her back, and they recognized it as being an issue. And it is an issue,” Fred Bendell told Global News in an interview.
“She was handled poorly.”
The military sent its report to the federal government after army medics reported witnessing shocking conditions at the five Ontario nursing homes where they had been deployed.
The Ontario government released the report on Tuesday after Global News published details of the findings. The province has asked the chief coroner to launch an investigation into the choking death.
On Wednesday, Premier Doug Ford announced the province was taking over the five long-term care homes, including Orchard Villa, which did not respond to requests for comment.
The 308-bed facility, owned by Southbridge Care Homes, has been clobbered by the pandemic, with 77 deaths and at least 96 staff and 225 residents testing positive for novel coronavirus.
Families have called for a police investigation into Orchard Villa, and have alleged neglect, malnourishment and failure to adhere to infection prevention protocols.
A $40-million proposed class-action suit was filed against Orchard Villa this week alleging negligence. The home has not yet responded to the civil action, filed in the Ontario court.
In their report, military personnel reported seeing “cockroaches and flies at the Pickering facility, while patients were “left in beds soiled in diapers.”
“Respecting dignity of patients not always a priority. Caregiver burnout noted among staff,” said the report, which also ranked infection prevention practices as “poor.”
But many of the military’s concerns related to how residents were being fed. Staff “aren’t always sitting up residents before feeding/hydrating/giving meds; choking/aspiration risk is therefore high,” read the report.
The report appears to be referring to June Bendell, who was born in Toronto and met her husband Harry in Grade 6. They were inseparable and would visit nursing homes at Christmas dressed as Mr. and Mrs. Claus.
“June was an enthusiastic knitter and used her knitting to share her love,” her obituary read. “Often, after a visit, the host would find themselves in possession of a new pair of woolen slippers or mittens.”
“That was her therapy, to sit and knit,” said her daughter Pamela Bendell.
Her mother had been at Orchard Villa since July 2009. She had Parkinson’s and dementia, and because she was prone to choking, she had to be elevated during meals.
To make sure she was fed properly, her family hired a personal support worker, and even placed diagrams above her bed showing how she needed to be positioned when she ate.
“So if you didn’t have time to read the chart, all you had to do was look at that picture,” her daughter said.
It could take 40 minutes to feed her. Her son said he understood it wasn’t easy. “But at the same time she has a need, we have a responsibility to make sure she gets fed properly.”
On the Friday before Mother’s Day, her children got a call saying she had choked and passed out when a staff member fed her a nutritional drink. Then they were told she had died.
They said they were not told she was lying flat when it happened.
“They should have elevated her,” said her daughter, a former employee of the nursing home.
Her son said someone with his mother’s condition had to be sitting up for meals or she would choke.
“That’s common sense,” he said.
“I mean the average person can’t swallow lying on their back, but in her case, she had to be elevated regardless of whether she was in bed or not to swallow properly. And if she wasn’t, she choked.”
The family said this was not their first problem at Orchard Villa. They claimed they once found her with a black eye. Someone had bumped her. Another time, her knee swelled up, but the family said the staff examined the wrong knee.
“My personal feeling is, I think long-term care should have always been part of the hospital system,” said Pamela Bendell. “When people have numbers to drive, what usually goes? They cut out food or they cut out education and training, the things that are needed so desperately.”
It bothers Fred Bendell that whenever he talks to anyone in their 70s, their biggest fear is going into a nursing home. It shouldn’t be that way, he said. He doesn’t think there is a place for profit in long-term care.
“We just owe it to these people. We’re here because of them. We owe it to them to take care of them, and we’re not doing it.”
“It’s just not right.”
Stewart.Bell@globalnews.ca