GLTCRC File number Number of Recs Summary of Case Recommendation(s) Theme of Recommendation
GLTCRC-2022-01 0 This case involved the death of an 86-year-old man who died from complications of hip fracture after being pushed by another resident of the long-term care home where they both resided. Not applicable Not applicable
GLTCRC-2022-02 3 The decedent was an 84-year-old female who lost vital signs at a retirement home. Concerns were raised by the family and the coroner that the deceased did not have the death without intervention that she desired, and that paramedic resources could be better used for patients that required their services.
  1. It is recommended that the Ministry of Health and Ministry of Long-Term Care should organize a committee to revise the current do not resuscitate (DNR-C) form. This committee should include broad medical and legal representation as well as representatives from EMS, the retirement and LTC home sectors and someone with lived experience. This review should also include a process to rescind consent for a DNR order.
    The form should not be overly complex but should be a viable, interoperable, digital format. It should include the designation of the regulated health professional obtaining the consent and their license number.
  2. In conjunction with this new form, education should be provided to regulated health care professionals (MD, RN, RPN, RN-EC), through their professional colleges, on the proper process for obtaining consent for a DNR order and completion of this form. This change would also necessitate the updating of the training manuals for EMS workers.
  3.  The current DNR consent forms of all residents and patients should be reviewed to ensure these forms are valid and properly completed. Homes should ensure that they have on site hard copies of the current, valid forms with serial number. Education for regulated staff should be provided on how to obtain consent and complete the current forms.
  1. Determination of Capacity/Consent for Treatment/DNR;
    Acute Care and LTC Industry
  1. Education and Training;
    Determination of Capacity/Consent for Treatment/DNR
  1. Determination of Capacity/Consent for Treatment/DNR;
    Acute Care and LTC Industry
GLTCRC-2022-03 0 This case involved the death of an 84-year-old female resident of a LTCH who died of complications of an undiagnosed duodenal ulcer. Not applicable Not applicable
GLTCRC-2022-04 5 The case involved the death of a 77-year-old female resident of a LTCH who died following complications of bronchopneumonia with an underlying undiagnosed lung carcinoma. Family expressed concerns related to follow up on abnormal imaging.
  1. Ontario Health should develop an integrated provincial Electronic Health Record (EHR) that provides the opportunity for transfer of information across healthcare sectors including community independent healthcare facilities to support the seamless transition(s) of care. This should include an opportunity for open access to health records to support patient centered approach to care.
  2. Primary care providers should ensure that a seamless transfer of care occurs when patients transition between care settings such as transfer from community primary care to retirement home and to long-term care home. This must include all recent and relevant investigations, consultation reports and specialist involvement including pending referrals. In addition, they should ensure there is a process in place to transfer reports, investigation results that they receive to the appropriate provider when no longer the most responsible provider for the patient.
  3. All medical directors and attending physicians working in long-term care homes in Ontario should have competency in care of persons with multi-morbidity, dementia care including diagnosis, assessment and management of behavioural symptoms and a palliative approach to care.
  4. A palliative approach to care should be a required competency for clinicians working in long-term care homes with a specific focus on consent to treatment, goals of care discussions and a palliative approach for persons with progressive dementia and multi-morbidity.
  5. Long term care homes and retirement homes should develop systems and processes that track the status and implementation of requests for consultation.
  1. Communication and Documentation; Transfers
  2. Communication and Documentation; Transfers
  1. Acute Care and LTC Industry; Education and Training
  2. Determination of Capacity/Consent for Treatment/DNR; Acute Care and LTC Industry
  3. Medical and Nursing Management; Acute Care and LTC Industry
GLTCRC-2022-05 7 The decedent was a 75-year-old woman who died of smoke inhalation from a house fire on June 26, 2020. Prior to her death in the house fire, she had a number of contacts with health care providers and the police. The GLTCRC was asked to review the death of this individual at the request of the Inquest Advisory Committee (IAC). The GLTCRC was asked to make recommendations to assist in preventing similar deaths in the future, provide an opinion as to whether a discretionary inquest may assist in prevention, and if there is a role for collaborating with the Office of the Public Guardian and Trustee.
 
  1. Health care providers, including first responders (paramedics, police and fire personnel), are reminded that seniors living alone, and particularly those with an altered mental status, are vulnerable persons and there is a heightened duty of care for all service providers.
  2. In situations in which the possibility of elder abuse has been raised, care providers are reminded to work as a team, including police as necessary, to establish if this is the case or not. An excellent, provincially funded resource is Elder Abuse Prevention Ontario
  3. In situations in which seniors are unable to access home and community care services by phone or virtual methods, clear and timely assessment and support must be offered in person.
  4. An easily accessible, PHIPA compliant, integrated health information system which includes home and community care services, is strongly encouraged.
  5. Clinical teams caring for seniors in the community, emergency room and other hospital settings are reminded that delirium is a common and serious presentation in the elderly. All care settings are strongly encouraged to have robust clinical pathways in place to identify, assess, and support seniors with delirium.
  6. When discharging seniors from the hospital on oxygen, it is strongly recommended that there be independent verification that the discharge destination have working smoke alarms.
  7. Current educational approaches to support the Health Care and Consent Act in practice are simply not working. The GLTCRC strongly encourages a re-invigorated program of education across the senior care sector to support providers assessing capacity for health care decisions in Ontario.
  1. Other
  2. Medical and Nursing Management; Education and Training
  3. Communication and Documentation
  4. Communication and Documentation
  5. Medical and Nursing Management
  6. Communication and Documentation
  7. Education and Training
GLTCRC-2022-06 6 This case involved the death of a 64-year-old woman with schizophrenia, who had been living in a LTCH. The family and Regional Coroner had concerns surrounding hygiene issues and care at the LTCH.
  1. Registered staff should be reminded of the medical concept of sepsis, including the importance of early recognition and early treatment which has been proven to reduce mortality and morbidity.
  2. There should be renewed emphasis on teaching the importance of full vital signs and that staff must follow up on abnormal vital signs.
  3. If a Doctor of Medicine (MD) has been called for a change in resident condition and does not answer, unless the situation is completely resolved, staff should call again to discuss and document the case. If the MD is still not available, consideration should be given to sending the resident to the hospital for examination and treatment.
  4. Standing orders for acetaminophen should be restricted to 1-2 doses per illness. Standing orders of several doses might delay diagnosis and treatment.
  5. Training of LTCH staff should include care of residents with non-cognitive psychiatric disorders (for example, schizophrenia).
  6. Residents with non-cognitive psychiatric disorders should have care plans that reflect any specific care issues in that regard.
  1. Medical and Nursing Management
  2. Education and Training
  3. Medical and Nursing Management
  4. Use of Drugs in the Elderly
  5. Education and Training
  6. Communication and Documentation
GLTCRC-2022-07 1 This case involved an 81-year-old male who died as a result of being pushed by another resident in his LTCH.
  1. LTC Homes in Ontario should be reminded to specifically include fracture prevention and not just fall prevention in their quality improvement activities (for example, through mandatory falls prevention and management programs). The Fracture Risk Scale in MDS-RAI may be useful to identify those at highest risk of fracture.
  1. Acute Care and LTC Industry
GLTCRC-2022-08 1 This case was referred to the committee as a mandatory review. The manner of death was determined to be a homicide after an 88-year-old woman died from complications of a hip fracture that she sustained after being pushed by another resident in the long-term care home where they both resided.
  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, routines and interactions with those already residing in the home. Careful supervision, documentation and behavioural care-planning are essential.
  1. Communication and Documentation; Acute Care and LTC Industry
GLTCRC-2022-09 5 This is a case of an 87-year-old male discharged from hospital Against Medical Advice (AMA) by his son who had Power of Attorney for Personal Care. The issues raised in this case and expressed by next of kin included “deficient care which led to the development of a large sacral ulcer, failure to provide proper infection treatment, and inadequate home care treatment for the sacral ulcer (paramount to neglect)”.
  1.  In cases in which a decision has been made to provide palliative care, the Primary Care Provider should be encouraged to continue to provide care. In addition, consideration should be given to
    1. referring to a Home and Community Care Support Services (HCCSS Palliative Care Nurse Practitioner to provide in-home palliative support to the patient, family and contracted service providers (even if there is a Primary Care Provider involved)
    2. referring to a Community Palliative Care Team for 24/7 support.
  2. Reinforce the importance for all contracted Service Provider Organizations staff to be compliant with the provincial (HCCSS) SAFE Reporting system for all patient safety events.
  3. Where a family member and/or legal Substitute Decision Maker (SDM) decides to take the patient home Against Medical Advice (AMA), a Hospital Ethicist should participate in the discharge-planning meeting with the family members/SDM.
  4. The Ministry of Health should ensure sufficient resourcing of HCCSS teams in order to support complex clients requiring 24/7 services.
  5. Safety indicators for home care to support reporting and quality improvement should be developed.
  1. Other
  1. Communication and Documentation
  2. Medical and Nursing Management
  3. Acute Care and LTC Industry
  4. Other; Communication and Documentation 
GLTCRC-2022-10 4 The case involved the death of a 90-year-old male resident of a LTC home who died following an injury sustained during a transfer using a mechanical lift. The referral to the GLTCRC was made at the request of the Regional Supervising Coroner due to concerns of care issues expressed by the coroner and family.
  1. The LTC home involved in this case should complete a quality review of this incident and practices regarding the use of mechanical lifts to identify improvements to prevent a similar incident in the future.
  2. When using mechanical lifts for patient/resident transfers, all providers should be aware of the risk of head and neck injury if the sling becomes loosened or undone during transfer. The risk of injury is heightened for those with underlying health conditions that may increase the severity of injury (that is, osteoporosis).
  3. Providers need to follow manufacturers’ instructions on the appropriate use of mechanical lifts including the use of 2 persons during the transfer. There should be a process in place to confirm prior to each patient transfer that the appropriate size of sling is being used and that there is a regular process to reassess the appropriate sling size on a regular basis for those requiring mechanical transfers on an ongoing basis.
  4. All providers should receive ongoing education and training on the safe use of mechanical lifts, including the importance of consistency in measurement and application of appropriate sling during patient/resident transfer and the use of 2 persons during the transfer. The committee recommends that this case and previous cases reviewed by the committee should be used in training for the sector.
  1. Medical and Nursing Management ; Acute Care and LTC Industry
  1. Medical and Nursing Management; Other
  2. Transfers; Education and Training
  3. Transfers; Education and Training
GLTCRC-2022-11 9 The Regional Supervising Coroner requested a review of this case of an 83-year-old female who died of acute and chronic dehydration after being transported from a Regional Hospital by a ground transport service, then a contractor for air ambulance, then ground transport to a Long-Term Care Home (LTCH). Her transfer was considered non urgent as she was an Alternate Level of Care (ALC) patient awaiting admission to the LTCH of choice. There were concerns that delays in her transfer may have contributed to her death.
  1. Hospitals should consider the regional hospital’s quality review recommendations such as:
    • the development of a check list for use prior to long or complex transfers
    • review and documentation of any family concerns prior to transfer and escalation of these concerns to the most responsible physician
    • ensure food, fluids and medications are provided to the transport team in the event there are delays in the transport
    • encourage physician to physician communication for non-hospital transfers.
  2. In person examination of a patient for stability prior to transfer out of the hospital should be performed.
  3. Physicians should be aware of where to find nutritional intake data in the electronic health record. Nursing staff must communicate poor oral intake of a patient to the physician. Management of the poor oral intake should be discussed with the patient or their decision makers in the context of the patient's disease and life expectancy.
  4. Patients with poor oral intake should be weighed on a regular basis.
  5. Hospitals should explore ways to support patients who require hand feeding such as communal dining tables with staff assigned to feed several patients where infection control practices permit.
  6. Physicians should be made aware of the impacts of trimethoprim/sulfamethoxazole on renal function in the elderly and that renal function should be checked once treatment is started.
  7. Hospital staff and physicians should be reminded that physical restraints are a barrier to patients self-feeding and being able to meet their own nutritional needs.
  8. Transport services should ensure that all phases of a patient's transfer are fully coordinated and confirmed prior to the transfer. The transport team should be aware of the nature of the patient's diet and have diet and texture appropriate food and fluids in the event of delays in transport.
  9. A further review of this death should be completed by the hospital involved with consideration of the findings and recommendations of the committee.
  1. Communication and Documentation
  2. Medical and Nursing Management; Transfers
  3. Medical and Nursing Management; Communication and documentation
  4. Communication and Documentation
  5. Acute Care and LTC Industry
  6. Use of Drugs in the Elderly
  7. Use of Restraints
  8. Transfers
  9. Medical and Nursing Management
GLTCRC-2022-12 6 This case involved an 89-year-old male who was the victim of resident-on-resident violence within a long-term care facility. This was a mandatory GLTCRC review of events since this death was classified as a homicide in Long-Term Care.
  1. Strategies to counteract the ‘normalization’ of violence should be considered when developing the Ontario Provincial Dementia Strategy.
  2. It is recommended that the Ministry of Health and Ministry of Long-Term Care consider, as a component of the configuration of a system-wide approach to responsive behaviours/ behavioural and psychological symptoms of dementia (BPSD), the establishment of an increased number of non-transitional long-term care home behaviour support units throughout the province for carefully selected individuals with severe and prolonged behavioural symptoms, adequately resourced and staffed with individuals trained to manage BPSD.
  3. Behavioral Supports Ontario should consider increasing transitional care planning with behavioral supports in the LTC facility when an individual suffering dementia syndrome with behavioral symptoms relocates to the LTC facility.
  4. Long Term Care facilities should consider increased staffing/higher intensity supervision while attempting to wean antipsychotics for behavioral symptoms of dementia.
  5. It is recommended that the Ministry of Long-Term Care consider increasing resources to support training and education of long-term care home staff and physicians in the management of responsive behaviors/BPSD), as well as to support increased staffing levels in long-term care homes geared towards mitigating responsive behaviors as opposed to basic functional needs.
  6. It is recommended that the Ministry of Long-Term Care consider funding research to investigate strategies to assess, predict, and manage resident to resident violence in long term care home with attention to variation among different long term care homes.
  1. Communication and Documentation
  2. Acute Care and LTC Industry; Other
  3. Acute Care and LTC Industry
  4. Acute Care and LTC Industry
  5. Medical and Nursing Management; Education and Training
  6. Acute Care and LTC Industry; Other
GLTCRC-2022-13 2 The Geriatric and Long-term Care Review Committee has been asked by the Regional Supervising Coroner to review this death. The decedent was an 86-year-old woman who died of hypothermia after becoming lost. The GLTCRC was asked to make recommendations to assist in preventing similar deaths in the future and provide an opinion as to whether a “Silver Alert Policy” might have been beneficial.
  1. It is recommended that the Ministry of Seniors and Accessibility and the Ministry of the Solicitor General explore whether a “silver alert” system for missing seniors should be implemented in Ontario.
  2. Police services should consider working with community agency partners to implement social work crisis outreach to follow-up on domestic incidents involving seniors.
  1. Other
  1. Other