The director of Ontario’s long-term care inspections branch has issued an order and directed Collingwood nursing home Sunset Manor to stop authorizing admissions to the facility due to concerns over a “risk of harm” for residents.
The order, which requires the home to retain new leadership at its own expense, was put into place after what the inspections director called “significant” and sometimes recurring findings of non-compliance related to abuse and neglect, skin and wound care, and nutrition and hydration programs.
Between July 2018 and May 2021, inspectors with Ontario’s Ministry of Long-Term Care (MLTC) visited Sunset Manor, which is owned and operated by the County of Simcoe, 17 times and recorded dozens of findings.
Despite inspectors’ observations and the previous orders issued, the ministry’s inspections director said the County of Simcoe didn’t take the “necessary” actions to address and correct “serious issues.” He also said the county has shown a “lack of understanding” of what’s required to address non-compliance.
Part of the issue, the inspections director alleged, is the home has had frequent turnover in leadership positions, which hasn’t allowed it to implement and maintain plans to ensure compliance.
Over the course of three years, the home has had three directors of care and three assistant directors of care, an MLTC document said. During past inspections, the home’s executive director had “minimal presence” in the resident areas and “very little engagement” with staff and inspectors, the document alleged.
“The decision to issue this director’s order is based on the scope and severity of non-compliance, and the licensee compliance history over the past 36 months,” the MLTC order read.
“The scope of non-compliance is identified as widespread in the home and represents systemic failure that affects or has the potential to negatively affect many, if not all, of the home’s residents.”
In a statement, Simcoe County’s general manager of health and emergency services, Jane Sinclair, said the county “strongly disagree(s)” with the severity of the MLTC’s findings.
“It is important to emphasize that the rates of incidents at Sunset Manor align with industry standards,” Sinclair said in a statement emailed to Global News.
“While we take any incident very seriously, we believe the orders are excessive, lack full detail on our actions and policies, and we believe there are extenuating circumstances that factored into the directives.”
Sinclair said the county must “reluctantly” bring forward that one of the ministry inspectors is a former county employee.
“Their involvement in the inspections and report is a conflict of interest,” Sinclair added. “We expressed these concerns to the ministry beginning in 2020 and again during this process.”
The ministry’s management order specifically outlines 31 findings of non-compliance. Of those, 10 relate to abuse and neglect.
Moreover, the ministry issued a compliance order as a result of an inspection that was conducted at Sunset Manor in April 2021, which found staff reported feeling “intimidated and fearful” to provide information to inspectors related to care concerns, abuse and neglect for fear of reprisal.
“Staff that did speak with inspectors shared they were interrogated afterward by management and advised that they should not be providing information to inspectors unless absolutely necessary,” the inspections director said in the MLTC document.
“Staff indicated that management advised staff that issues should be dealt with ‘in-house’ and that inspectors used tactics to get information.”
The inspections director said some staff asked to talk offsite because of fear of reprisal and some staff wished to remain anonymous when providing information for fear of retaliation.
In one instance, the MLTC said a resident with a complex medical history didn’t have the necessary monitoring for one of their chronic medical conditions during a 10-day period and didn’t receive nutrition and hydration for a point during that time because staff weren’t trained on how to deliver that type of nutrition and hydration.
“The lack of nutrition and hydration for this time period, combined with no monitoring of the chronic medical condition, put the resident at continued risk of harm,” the document said.
“After the resident’s death, a coroner’s investigation identified that there was no process in place to monitor the resident’s chronic medical condition.”
In another instance, the inspections director said a resident experienced a health condition over several months that required intermittent hospitalizations and treatment. The director said the resident’s health declined over a short period of time, and as a result, they required readmission to the hospital.
“The physician was not notified when the resident’s health status deteriorated, a pain assessment was not done when the resident exhibited signs and symptoms of pain,” the MLTC document said. “The resident’s re-weigh was not completed even though the RD had requested it. There was failure to provide treatment and care from staff as required for the resident’s health, safety and well-being.”
In her response to the ministry report, Sinclair said the County of Simcoe has a “longstanding history of excellent care and services at Sunset Manor.”
“This inspection report does not reflect this outstanding level of care that is delivered to our residents,” she added. “Our staff, residents and families can rest assured that the quality of care we provide will not be impacted by these unwarranted and excessive findings.”
Sinclair said residents and families should ask why the ministry’s report is coming out now and “creating further impact” on residents and staff when the home “has done so well to fight COVID and has a great record and history of caring for residents.”
“We strive for continual improvement in all our homes, while we believe we have some of the highest standards in care in the province,” Sinclair added.
“As we seek to enhance our services always, we welcome inspections, feedback and expertise into our policies and protocols.”