GLTCRC File #Number of RecsSummary of CaseRecommendation(s) and (Theme)
GLTCRC 2020-011This case involved the death of a 63-year-old woman who died from bronchopneumonia due to neurodegeneration with brain iron accumulation, in association with a fractured hip. The etiology of the hip fracture could not be determined. The woman utilized some alternative medicines and just prior to her death, there were allegations that she may have been given a noxious substance.
  1. Clinicians in hospital emergency departments should develop a systematic approach to assessing vulnerable adults. Consideration should be given for a full detailed exam, if possible, by a practitioner or team experienced in forensic medicine, and skeletal survey, for any vulnerable individual in all credible cases of alleged abuse. (Medical/nursing management)
GLTCRC 2020-023This case involved the death of a 79-year-old man with advanced Alzheimer’s Dementia who died after an altercation with another resident LTCH where they both lived. This was a mandatory referral to the GLTCRC as the manner of death was homicide.
  1. Long-Term Care Homes are reminded that newly admitted residents are at higher risk for involvement in violence (either as perpetrators or victims) due to unfamiliarity with a new environment, caregivers and routines. Careful supervision, documentation and behavioural care-planning are essential. (Medical/nursing management; Communication/documentation)
  2. The “normalization” of violence should be considered when developing the Ontario Provincial Dementia Strategy by the MOHLTC. (Acute and long-term care industry, including MOHLTC)
  3. Behavioral Support Ontario resources should be made available to all long-term care homes across Ontario to a degree that enables safe care of residents with dementia. (Acute and long-term care industry, including MOHLTC)
GLTCRC 2020-032This case involved the death of a 68-year-old man with a history of alcoholism and multiple co-morbidities who was found incapable for medical, personal and financial decision-making by a geriatric medicine physician. The decedent appealed the decision to the Consent and Capacity Review Board and was subsequently deemed capable. The man was found deceased at home twelve days after the decision regarding his capability.
  1.  Capacity assessors are reminded that decisions regarding capacity cannot be made solely on a face-to-face assessment with the client. Assessment should include information from family, professional care-givers or multi-disciplinary consultants and review of objective records. The assessment should also include a judgement as to the ability of the client to follow through on their intentions. (Determination of capacity and consent for treatment / DNR)
  2. The Ministry of the Attorney General, Ministry of Health, Retirement Home Regulatory Authority and College of Physician and Surgeons Ontario should consider collaborating on a broad educational initiative throughout the medical sector regarding consent and capacity.(Determination of capacity and consent for treatment / DNR)
GLTCRC 2020-045The decedent was an 83-year-old female who lived in a LTCH. She died from complications of a fractured hip after experiencing a fall out of bed while being cared for by an individual personal support worker (PSW). One month prior to the incident, two half-bed rails had been removed from the woman’s bed. Concerns were raised about the use of bed rails and communication with families.
  1. Medical schools and continuing education for physicians and nurses should emphasize least-restraint policies, including the use of partial bedrails and personal assistive supportive devices when they can be safely used. (Use of restraints)
  2. Residents/patients and their substitute decision-makers/families should be consulted when restraint devices like bedrails are implemented or are removed. Discussions regarding the addition or removal of devices should be documented. (Use of restraints)
  3. It is recommended that Health Canada require near miss falls to be reported and acted upon just as near miss entrapments currently are. (Communication/ documentation)
  4. It is recommended that corporate policies in long-term care homes should be developed not to simply eliminate bedrails, but to emphasize resident/patient preference and com-fort, as well as safety, and to fully involve the healthcare team, the resident/patient and their family and/or substitute decision maker.(Other; Acute and long-term care industry, including MOHLTC)
  5. The Ministry of Long-Term Care should amend the Long-Term Care Act to provide more concise direction for the addition and removal of bedrails and personal assistive support devices. (Acute and long-term care industry, including MOHLTC)
GLTCRC 2020-052This case involved the death of an 84-year-old woman with a medical history that included chronic obstructive pulmonary disease and congestive heart failure. This case was referred to the GLTCRC due to concerns regarding the quality of care at the LTCH where she resided. 
  1. When nurses modify a physician’s orders, a full rationale should be provided in the progress notes, and the physician should be notified at an appropriate time. (Communication/ documentation)
  2. The MOHLTC should explore the ethical and legal aspects of hidden cameras placed within long-term care homes without the knowledge and/or consent of the facility’s administration and staff. This review may benefit from input from a medical ethicist and legal expert. (Acute and long-term care industry, including MOHLTC)
GLTCRC 2020-060This case involved the death of an 89-year-old woman receiving palliative care. Concerns were raised by the decedent’s family regarding the quality of end-of-life care provided in the long-term care home where the woman lived.Not applicable
GLTCRC 2020-0710The case involved the death of an 89-year-old woman who died in the retirement home where she lived. This case was referred to the GLTCRC at the request of the coroner, police and family due to concerns regarding inappropriate “Do Not Attempt Resuscitation” forms and concern regarding treatment delay or omission.
  1. Electronic “do not resuscitate” (DNR) validity forms should be immediately accessible in the Connecting Ontario portal. This should be a living document that is accessible to all healthcare providers. (Communication/documentation)
  2. The regulatory regime should be revised to include a review of quality of care in all long-term care settings regardless of the setting of care (i.e. retirement home or long-term care home) where the care provided should meet the needs of the resident including their medical care needs. (Acute and long-term care industry, including MOHLTC)
  3. A mechanism to implement the Transitions in Care Quality Standard should be developed. (Acute and long-term care industry, including MOHLTC)
  4. A mechanism should be developed and implemented to communicate with all care providers when a palliative approach to care has been agreed to. This could be similar to work on the coordinated care plan that has previously been developed. (Communication/documentation)
  5. All new admissions to retirement homes should require a comprehensive history and physical upon admission in addition to any information completed in the initial application. (Medical/nursing management; Acute and long-term care industry, including MOHLTC)
  6. Retirement homes should implement mechanisms to support quality transitions in care on admission as per the Health Quality Transitions between hospital and home Quality Standard . (Communication/documentation)
  7. Retirement homes should be required to implement electronic medication administration records (MARs) to avoid the potential medication errors with paper MARs particularly with acute changes in resident status. (Communication/documentation)
  8. Prescribers are reminded that a substantial change in therapeutics requires clear documentation. (Communication/documentation)
  9. Physicians are reminded of continuity of care policy and potential harm that can occur with inadequate transfers of care. (Medical/nursing management)
  10. While appreciating the pressure for timely discharge from acute care, discharge planning should include an understanding of the medical and nursing care needs of individuals when finalizing discharge plans. (Medical/nursing management)
GLTCRC 2020-082This case involved the death of a 100-year-old woman residing in a LTCH who died from neck compression after slipping down the seat of a wheelchair that had a seatbelt lap restraint. 
  1. Long-term care homes and families should be made aware that, though rare, deaths can be caused by lap belt wheelchair restraints in dementia patients. (Use of restraints)
  2. Clear indications should exist for the initiation of wheelchair lap belt restraint, with risks and benefits discussed with substitute decision makers/family, and documentation of these discussions in the clinical record. (Use of restraints; Communication/documentation)
GLTCRC 2020-094The decedent was a 76-year-old man. Concerns were identified regarding his oral intake of food and fluid, increased number of falls and the lack of a complete physical examination by a primary care provider upon admission to a LTCH.  
  1. Nurses and physicians in long-term care homes are reminded that when there is a change in the health status of a resident, a comprehensive assessment should be done to diagnose and treat whatever the underlying medical problem may be, particularly when the changes occur immediately upon or after admission.  (Medical/nursing management)
  2. The long-term care home involved should conduct a medication review for residents under the care of the attending physician. (Medical/nursing management; Use of drugs in elderly)
  3. The Ministry of Long-Term Care should consider reviewing the function and purpose of long-term home investigations and inspections. The current focus of reviewing compliance to a set of regulations does not adequately review medical and nursing quality of care provided. (Acute and long-term care industry, including MOHLTC)
  4. When conducting assessments of high-risk residents in long-term care homes, every effort should be made to determine estimated food intake. An entry of “not applicable / not available” is insufficient. (Medical/nursing management)
GLTCRC 2020-105The decedent was a 31-year-old man with a severe developmental delay characterized by autism, a seizure disorder, and bipolar spectrum disorder, who lived in a group home. The man was found deceased in a vacant room where he was being isolated during a behavioral crisis. This case was reviewed by the GLTCRC as the decedent lived in a long-term residential setting in which he was dependent on staff for care of his complex developmental and psychiatric conditions.
  1. Group Homes providing residential care to adults with developmental delay are reminded of their obligation to provide care consistent with the standards stated in SIPDDA, 2008, and in accordance with Ontario Regulation 299/10. In particular, group homes are reminded to:
    • have well-documented behavioural care plans
    • adopt a least-intrusive approach
    • work with health care providers in the development of behavioural care plans
    • clearly document indication, observation, and consequence of more intrusive behaviourial management supports such as “quiet rooms.” (Medical/nursing management)
  2. The MCCSS should establish a regular inspection regime to perform in-person annual inspections of all group homes in Ontario to ensure compliance with legislation and regulation, specifically involving support of adults with developmental delay and complex behavioural needs. (Acute and long-term care industry, including MOHLTC)
  3. The MCCSS should develop regulations and supports for group homes to ensure that all staff who provide medication to residents have the knowledge, skill, and attitudes to be able to do so safely. (Medical/nursing management)
  4. Transitions in care are a time of particular risk for patients who are developmentally delayed. Clear discharge plans, including key instructions for seeking assistance if the patient’s condition deteriorates, are essential. (Medical/nursing management)
  5. Physicians working with the developmentally delayed population are reminded that all treatment must occur with informed consent under the Health Care and Consent Act. This means explicit documented conversations with the patient if capable, and if incapable, with a substitute decision maker as defined within the Health Care and Consent Act. (Determination of capacity and consent for treatment / DNR)
GLTCRC 2020-112This case involved the death of an 85-year-old man following a motor vehicle collision. Concerns were raised as the man had mild cognitive impairment (MCI) and still had a valid driver’s license.
  1. It is recommended that the Ministry of the Solicitor General and the Ministry of Transportation consider the development of a provincial alert system to rapidly locate older adults who are missing, including when they are thought to be driving a motor vehicle. (Other) 
  2. It is recommended that the College of Physicians and Surgeons Ontario remind physicians (perhaps through the CPSO publication Dialogue) about the importance of assessing and documenting driving safety in all patients with neurocognitive disorders, including mild neurocognitive disorders, and reporting to the Ministry of Transportation those individuals who may no longer be fit to drive due to cognitive impairment, based on accepted criteria. (Communication/documentation)
GLTCRC 2020-122This case involved the death of an 83-year-old man who was a resident of a LTCH. The man died after a medication error where he was prescribed morphine 1–2 mg and inadvertently administered 10 mg.
  1. It is recommended that the Ministry of Health add morphine 10mg/ml and 2mg/ml to the regular Ontario Drug Benefit (ODB) formulary. These dosages are currently listed as “limited use” for palliative patients only. (Use of drugs in the elderly)
  2. Naloxone, together with staff training on how to administer it, should be available in all long-term and retirement facilities where residents may be on opioid therapy. (Use of drugs in the elderly)
GLTCRC 2020-132This case involves the death of a 77-year-old man following a physical altercation with another resident of the LTCH where they lived. His family expressed concerns regarding the care he received in the home and the delay in sending him to hospital.
  1. The Ministry of Long-Term Care and Behaviour Supports Ontario should develop at tool kit of escalating resources for each community to support them in addressing the needs of individuals with violent and aggressive behaviours who reside in long-term care homes. This should include access to virtual assessments where needed with a goal of safety in long-term care for all residents and staff. (Acute and long-term care industry, including MOHLTC)
  2. The requirements to obtain supplemental staffing should be reviewed and revised to facilitate the use of extra staffing for the safety of the residents and staff of long-term care homes. Long-term care homes are reminded that a physician's order is not required to obtain supplemental staffing. (Acute and long-term care industry, including MOHLTC)
GLTCRC 2020-141This case involved the death of a 74-year-old woman with several medical comorbidities and delirium. The woman had multiple visits to hospital and had been assessed by geriatrics and psychiatry. Concerns were identified about the level of care provided at the hospital, particularly the attribution of her presenting symptoms to non-medical causes.
  1. A structured approach to delirium recognition and management is a key component of hospital care for seniors. This must include clear communication between patients and families, and the clinical team about diagnosis, treatment, and prognosis of delirium in the elderly. (Medical/nursing management; Communication/documentation)
GLTCRC 2020-153This case involved the death of a 94-year-old woman who died from complications of an unwitnessed fall while a resident in a LTCH. Concerns were identified regarding management of responsive behaviours in the LTCH and care provided to the decedent after the fall.
  1. Physicians providing services in long-term care homes are reminded that resident/patient reassessment should occur in a timely and comprehensive manner whenever there is a change of status. (Medical / nursing management)
  2. Physicians providing services in long-term care homes should consider continuing professional development regarding appropriate prescribing with tools such as the Beers criteria. (Medical / nursing management)
  3. Nursing staff that administer ‘as needed’ opioids for analgesia should conduct pain assessments that are anchored to validated assessment scales e.g. PAINAD scale. (Use of drugs in the elderly)
GLTCRC 2020-161This case involved the death of a 69-year-old woman. This case was referred to the GLTCRC because of complications regarding wound care post fall and a medication error during hospital admission. 
  1. Healthcare providers are reminded that any fall involving an elderly person requires a thorough evaluation, including a critical review of all medications. It is recommended that the evaluation include internal medicine, geriatrics and nursing. (Medical/nursing management)
GLTCRC 2020-170The decedent was an 84-year-old man who died from congestive heart failure and an upper gastrointestinal bleed after experiencing a hip fracture and being placed on anticoagulation therapy. Concerns were raised as to whether post-operative anticoagulation contributed to the death. Not applicable
GLTCRC 2020-181The case involved the death of a 93-year-old male resident of a LTCH who died following diagnosis of a subdural hematoma while being treated in an acute care hospital. Concerns were raised regarding fall prevention and the assessment of an elderly person on anticoagulants who falls and then develops an altered level of consciousness.
  1. Physicians are encouraged to have a low threshold when considering a CT head in older adults receiving anticoagulation in the context of an unwitnessed fall, particularly with a history of change in level of consciousness if consistent with goals of care for surgical intervention. (Medical/nursing management)
GLTCRC 2020-190This case involved the death of an 84-year-old man who died after being pushed by another resident in the LTCH where they both resided. This was a mandatory referral to the GLTCRC as the manner of death was homicide.Not applicable