Ombudsman recommends changes to improve care at Middlechurch Home

An ombudsman investigation into complaints about the quality of care at Middlechurch Home, a long-term care facility, has made eight recommendations in areas ranging from suicide prevention to administering oxygen, CBC News has learned.

A complaint by a whistleblower triggered the review by the provincial ombudsman, which looked at 13 allegations spanning a two-year period from 2012 to 2014.

"The ombudsman's report and their recommendations is something we're taking very seriously," said Gina Trinidad, chief operating officer for long term care at the Winnipeg Regional Health Authority, which operates the home.

"We're going to use the report and the recommendations to further improve our procedures and enhance our staff education," said Trinidad.

She said the investigation looked into whether there was wrongdoing on the part of the facility or any employees regarding care and found there was none.

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The allegations did not deal with any deaths at the 197-bed care home, but two incidents examined could be considered critical incidents, Trinidad said. Under Manitoba law a critical incident typically involves a serious unintended consequence suffered from health services.

The WRHA provided CBC News with the recommendations but said the full report was not being released due to patient confidentiality. The WRHA will hold a forum later this month to discuss the report with Middlechurch residents and their families.

One recommendation was that Middlechurch develop a policy or procedure to follow when a resident succeeds in leaving the facility unescorted.

Trinidad said the vast majority of Middlechurch residents are able to leave the home unescorted. If residents are not in that category, a "code yellow" is typically implemented when someone is missing, she said.

In one case that was reviewed, "although code yellow was not called, there was an opportunity to improve the staff response," Trinidad said, noting there was no harm to the resident involved.

She said all 39 of Winnipeg's personal care homes have a code yellow policy for when someone is missing but not all the homes have a policy around leaving unescorted.

Suicide prevention policyneeded

The ombudsman also recommended a policy should be developed for when a resident attempts to commit suicide.

"There was an incident where an individual was threatening suicide. Staff did respond to that," said Trinidad. "There's always opportunity to look at our procedures, ensure that we're improving on those procedures."

The recommendation said, "The policy should address whether an emergency code would be activated, what reports should be completed, who should be informed, timelines for reporting, and steps to limit the risk of suicide."

The recommendation noted the policy will be developed by September 30, 2016.

Trinidad said a WRHA working group on suicide prevention in long term care was set up last year to develop a protocol for the entire health region.

"The group is really tasked with looking at standardizing our protocol -- the assessments, the interventions we take when there is suicide risk of our residents," she said.

Staff training for oxygen therapy

The ombudsman also reviewed two cases involving the administration of oxygen therapy to residents. Although Trinidad declined to give details of what happened, she said "there were certainly opportunities for improved communication among staff, and documentation."

"It's assuring that staff are aware of the procedures around that -- what their responsibilities are when they're administering oxygen to a resident," Trinidad said.

The ombudsman recommended Middlechurch "provide refresher training for all staff who will be expected to administer oxygen therapy to ensure consistent application and documentation of the policy and procedures."

When it comes to critical incidents, the ombudsman recommended Middlechurch review its policy "to ensure that all care staff, supervisors, and management understand the criteria of what comprises a critical incident" as well as the responsibilities of any person who witnesses or becomes aware of a reportable incident.

Another recommendation was that Middlechurch consider disclosing a summary of critical incident investigations and recommendations as a potential learning opportunity for staff.

Trinidad said the ombudsman found critical incidents "were largely being reported appropriately".

A recommendation arising from a resident who hit her head was also reviewed by the ombudsman, resulting in a recommendation that Middlechurch conduct additional staff training about head injury procedure.

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Middlechurch home was previously operated by a board of directors but was taken over by the WRHA in 2014. That followed a 2012 report by the provincial ombudsman that found mismanagement of public funds at the facility.

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