New Brunswick’s outgoing child, youth and senior advocate says in his latest report the death of an elderly man in a nursing home was preventable.
Norm Bosse released “He earned better: A man’s last days in long-term care” on Thursday. It was a scathing report that said the nursing home did not communicate properly 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 suffering three assaults, with the last one ending up in hospital for a hip fracture.
“In all the circumstances of this case, I felt that George’s death should have been prevented,” he told a news conference on Thursday. “The old age home should have taken greater care to intervene with Tom and provide greater supervision.”
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Tom, whose identity is also secret, was a patient with dementia for whom violent incidents have been recorded in the past. He was the one who allegedly bumped George on the ground leading to his hip fracture.
The family was reportedly notified their father had fallen, not that he had been assaulted by another patient. George’s death occurred within 10 weeks of his admission to the nursing home – which is not mentioned in the report.
Tom, in this case, was only admitted two weeks before George. The report indicates that staff expressed concern about what Tom was causing and that he should be kept away from George, but the report says staff indicated “that concern fell on deaf ears.”
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It also aimed at an internal investigation conducted by the Department of Social Development.
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“Our report documents the various shortcomings and shortcomings of the department’s internal review,” Bosse said. “First by not finding that the nursing home has failed in its duty to provide a safe living environment where residents are protected from assault, neglect, and where their interactions and clients are managed to prevent incidents of abuse or triggers that could cause harm to one client, to avoid another. ”
The internal review found no wrongdoing on the part of the nursing home, but Bosse’s report said several people were not questioned and it relied too heavily on what the management told them about the incidents.
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“The Adult Protection Review and Liaison Officer Investigation failed to consider the nursing home’s failure to follow practice standards in connection with their communication with George’s family,” he said in his opening speech. “Failure to inform them of major incidents that have taken place and failure to complete the family audit regarding their father’s care. Fourthly, the department failed to take note of the absence of insufficient complaint processes at the old age home with appropriate follow-ups and case resolution. ”
Bosse said he did not believe insufficient staff played a role in this particular case, but said it was clear that management did not acknowledge that there should have been one-on-one supervision of patients showing violent tendencies, including those with dementia.
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He also said George was illegally discharged from the nursing home three days before his death without an explanation.
Social Development Minister Bruce Fitch told reporters on Thursday he could not speak with the details of any case but was prepared to address the recommendations in the report.
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He was asked directly whether New Brunswick families can trust that when incidents are reported, they will be properly investigated, in light of the report.
“We will make sure that those investigations are done again,” he told a news conference on Thursday. “Certainly, part of the task here today is to take the recommendations based on the report that was issued today. Specifically for inspections,… if there is anything we need to change in our procedures… it will be done. ”
Fitch will not commit to a timeline on when the 13 recommendations will be implemented.
The recommendations included:
- Protection of nursing home residents.
- Report of major incident.
- Complaint process.
- Staff training.
- Communication with family members of nursing home residents.
- Adult protection examinations in old age homes.
- Independence and oversight of reviews of geriatric deaths and critical injuries.
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