New Brunswick’s outgoing child, youth and seniors advocate says in his latest report the death of an elderly man in a nursing home was preventable.
Norm Bosse released “He deserved better: A man’s final days in long-term care” on Thursday. It was a scathing report which said the nursing home failed to properly communicate with the family and the department’s internal investigation placed too much weight on what management said happened.
George, whose real identity is protected for privacy reasons, died after sustaining three assaults, with the last one landing him in the hospital for a fractured hip.
“In all the circumstances of this case, I have found that George’s death should have been prevented,” he said in a news conference on Thursday. “The nursing home should have exercised greater care to intervene with Tom and provide greater supervision.”
Tom, whose identity is also secret, was a patient with dementia for whom there were recorded violent incidents in the past. He was the one who allegedly pushed George to the ground resulting in his fractured hip.
The family, according to the report, was notified their father had fallen, not that he was assaulted by another patient. George’s death happened within 10 weeks of his admission to the nursing home — which is not named in the report.
Tom, in this case, had only been admitted two weeks prior to George. The report indicates staff has raised concerns about what would trigger Tom and that he should be kept away from George, but the report says staff indicated “those concerns fell on deaf ears.”
It also took aim at an internal investigation conducted by the Department of Social Development.
“Our report documents the several shortcomings and failings of the department’s internal review,” Bosse said. “First in failing to find that the nursing home neglected its duty to provide a safe living environment where residents are protected from assault, neglect, and where their interactions and clients are managed to avoid incidents of abuse or triggers that may cause one client to harm another.”
The internal review found no wrongdoing on the part of the nursing home but Bosse’s report said several people were not interviewed and it trusted too firmly in what management told them about the incidents.
“The Adult Protection Review and Liaison Officer Investigation failed to consider the nursing home’s failure to follow practice standards in relation to their communications with George’s family,” he said in his opening remarks. “Failing to notify them of major incidents that occurred and failing to complete the family audit in relation to their father’s care. Fourthly, the department failed to take note of the absence of inadequate complaint processes at the nursing home with appropriate follow ups and case resolution.”
Bosse said he doesn’t believe inadequate staffing played a role in this particular case but said it is clear management didn’t recognize that there should have been one-on-one supervision of patients who show violent tendencies, including those with dementia.
He also said George had been wrongfully discharged from the nursing home three days prior to his death without an explanation.
On Thursday, Social Development Minister Bruce Fitch told reporters he couldn’t speak to the specifics of any case but was willing to address the recommendations in the report.
He was asked directly whether New Brunswick families could trust that when incidents are reported, they would be properly investigated, in light of the report.
“We will, again, make sure that those investigations are done,” he said in a news conference Thursday. “Certainly, part of the task here today is to take the recommendations based on the report that was put out today. Specific to inspections, … if there is anything we need to change in our procedures … that will be done.”
Fitch would not commit to a timeline on when the 13 recommendations would be put in place.
The recommendations included:
- Protection of nursing home residents.
- Major incident reporting.
- Complaint process.
- Staff training.
- Communication with family members of nursing home residents.
- Adult Protection investigations in nursing homes.
- Independence and oversight of reviews of geriatric deaths and critical injuries.