Daughters want an investigation two years after their father fell three stories from a retirement home in Windsor
About three weeks after her father was transferred to a retirement home in Windsor, Ontario, Joan Vandererden didn’t expect she would receive a call telling her that the 80-year-old had been taken to hospital after falling from his third home. Floor window.
Nearly two years later, the family is still searching for answers.
“How did this happen? We put him there to be safe,” said Vandererden, whose father died the day after the fall.
“This should never have happened. He was healthy. We could have spent many more years with him, and now we don’t.”
Her sister, Susan Dixon, said she “never thought in a million years” that this would happen to her father, James Clark.
“It was devastating,” Dixon told CBC News.
The girls and their lawyers are waiting to hear whether the investigation they requested will be granted in September 2022.
Investigations by the Retirement Homes Regulatory Authority (RHRA), a committee of the coroner’s office and the Windsor Police Service, found that the home complied with regulations and there was no criminal neglect.
Although these inquests have produced some recommendations, the family want to see tangible change and believe a coroner’s inquest is the best way to achieve this. They also plan to file a lawsuit against the nursing home.
“This will answer some questions about what exactly failed in this process that allowed this to happen,” said Colleen Casa, a family attorney working with Goldstein DiBiase.
The lawyer said the investigation would help bring closure to the family.
Clark was diagnosed with dementia in December 2021, but it is still in the early stages, Vandererden said. In April 2022, Clark ended up in the hospital after some behavioral issues and had a tendency to wander off.
After about two weeks of hospitalization, Clark was moved to a “secure unit” at Lifetimes on Riverside Retirement Residence, which the family says takes in people who need memory care. The family said this was supposed to be temporary until a long-term care place opened.
Soon after Clark’s stay, his care plan was updated to include check-ins every 30 minutes, including throughout the night, the family said.
But the investigation showed that on the night Clark drowned to his death, these tests had not been performed.
CBC News has not seen a copy of the RHRA’s inspection, but said in an email that the home was found compliant.
CBC News obtained a copy of the investigation conducted by the coroner’s office’s Geriatric and Long-Term Care Review Committee. “The opinions expressed here do not necessarily take into account all the facts and circumstances surrounding the death,” the report warns.
In an interview, a personal support worker (PSW) who was on duty that night said Clark was last seen sleeping in bed at midnight on May 15, 2022, she said.
The light was on but no noise was heard
The report states that the PSW’s last attempt to check in on Clark was at 3 a.m., and at that time, the PSW was unable to open the resident’s door with the key.
“The light in the room was on but no noise was heard,” the report says.
“The PSW is no longer supportive of trying to open the door.”
It was later discovered that Clark had stuffed something into his unit’s key lock to keep people out.
They also found that he had dismantled his window, including the mechanism that prevented the window from opening more than two inches.
“I just wanted to crawl out the window and go home.”
“He probably thought he was on the main floor and just wanted to crawl out the window and go home,” Vandererden said.
“He went out the window and fell flat on his face. Everything in his head shattered and his skull cracked.”
At 5:30 a.m., an employee heading to work found Clark lying on the sidewalk in front of the house.
He was described as “unresponsive, but trembling and clearly injured,” the commission’s report said. An ambulance took him to the hospital.
At the hospital, Vandererden said the doctor came and told her that Clark had “catastrophic” injuries.
“He looked bad,” she said.
“It was really bad… We were in shock. When we saw him like that, so damaged, it was completely unrecognizable to his face.”
The Aged and Long-Term Care Review Committee report notes that “neurosurgery recommended a conservative plan of care” and that the family changed it to “comfort care.”
“He was extubated and…died from his injuries.”
He died on May 16.
The commission found that the death could not have been prevented
“Without constant supervision, and given the failure of the mechanical window barrier in place, the death of the deceased could not have been prevented even with perfect charting (dementia monitoring system) and intermittent direct monitoring by the PSW as planned,” a statement from the WHO said. . Committee report.
The report acknowledged that Clark’s death could have been prevented if there had been a tamper-resistant window locking mechanism.
Many health care facilities have policies about designing windows in “secure perimeter units,” she said. BC lists as an example and says it has standards about making windows impact-resistant and installed “tamper-resistant.”
The report says these standards are not enforced in Ontario nursing homes.
In an email statement, Lifetimes on Riverside general manager Jacqueline Elford said the death was an “unfortunate accident.”
The committee gave the hospice one recommendation: conduct a “qualitative review of the circumstances” of the death, “including consideration of perimeter security.”
What was recommended by the committee
The home has begun the review and will submit a response to the committee’s recommendation by the April 13 deadline, Elford said.
“Any lessons learned from this review will help us continue to improve the care, safety and comfort of residents,” Elford said in an email.
The Geriatrics and Long-Term Care Review Committee has made three other recommendations to other government agencies and ministries, the coroner’s office said in an email.
Two of them were directed to the Department for Aged Care and Accessibility and the RHRA, and said they should “review the need for security standards for retirement homes that provide secure units. This should include window security”.
It also recommended that because patients have more complex needs, they need to “consider appropriate organization (physical aspects of accommodation, minimum staffing levels and qualifications, delivery of medications), to improve resident safety.”
During Clark’s stay, the facility, which has capacity for 136 residents, was staffed overnight with one nurse buoy, one PSW buoy and one PSW assigned to Clark’s floor, the report said.
A spokesperson for the Ministry of Seniors and Accessibility responded to a request for comment on the recommendations.
An RHRA spokesperson said: “As it is within the RHRA’s authority to establish policies and procedures that address the recommendations in the report, it is in a better position to respond to them.”
The Hospice and Long-Term Care Review Committee also made a recommendation to the Ministry of Health and the Ontario Hospital Association, stating that when sending dementia patients to retirement homes, “decision-makers should take into account that these residences do not provide dementia or behavioral management.” Services and do not have staff for such.”
The coroner’s office said there is no legal requirement to implement these recommendations, but organizations or bodies must respond within six months.
She said none of them have returned yet, but they have until April.
No timeline given for possible investigation: coroner
The coroner’s office said it is difficult to know how long it will be before the family knows if an inquest will be held because “each case is unique, but all information, reports and records must be reviewed to make a decision.”
When asked how to detect retirement home compliance when a resident has not been checked in according to their care plan, the RHRA said there are no requirements in the Retirement Homes Act setting out “the number of times staff must routinely check on residents.”
“The frequency of checks or care depends on the agreement between the resident and the home taking into account the resident’s care needs and the home’s internal policies,” the RHRA said.
Graham Webb, an attorney and executive director of the Elder Advocacy Center, said this situation indicates a “systemic problem.”
“The flaw is in how we use retirement homes. Retirement homes should not be used as an alternative to the health care system, nor should they be a private paid health care system,” he said.
“We are trying to make a change.”
“We need a systemic change in the way we use nursing homes… they should not be used as a last resort for people who don’t fit anywhere else within the system,” Webb said.
He wants to see an investigation into this situation because he believes it could be helpful and would likely lead to law reform.
Vandererden and Dixon said they just want to make sure this doesn’t happen again to anyone else.
“We’re trying to make a difference,” Vandereden said.
“We are very frustrated that there are so many roadblocks, minimal procedures, and no real recourse.”