With Out Prejudice
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Firstly I would like to start Mom's story by telling you the reasons why we are undertaking this endeavor.
Please understand that it is not our intention to seek any financial compensation for our part at this time, not from the Federal or Provincial Governments, The Capital Health Authority, or even from the care center Mom was in. In that same vein it is also not our position to lobby for increased financial involvement from any layer of government. It is our belief that somehow these privately owned, government funded care centers should be able to make things work with the approximate $5200.00 per month, plus extras (phone, laundry) they receive per resident.
Our concern is that there would be some type of tangible accountability for those individuals and organizations who participated in our Mother’s demise.
Also, we want to let the public know from a personal stand point just what to expect while an individual is in the extended care system. Now that is not to say that every facility you or your loved one may be in is bad. Just information from our own personal experience, backed up by the documentation we were able to acquire. (Please be advised all documents will have names and location blacked out)
We would also like to let you know that we were under no delusions as to the state of our Mom’s condition. She entered the extended care system with some obvious problems. No one goes into this type of care if they are in perfect health. However, it is our desire to show you just what happened to her after she entered the system.
It begins…
On March 24th, 2005 Mom was discharged from a major Edmonton hospital into a local long term care facility.
As you can see in the "Discharge Management Plan" Mom was to be on a High calorie diet and weekly blood work of electrolytes to assess potassium. Was this done? Well we don’t know for sure because until we requested Moms chart from the hospital we were not aware of this. We also have not been able to acquire Mom's chart from the care facility itself. You see although they are required to by law to provide the records, they won’t give them to us. Please feel free to examine each of the requests we made for these documents.
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Doctors Discharge Summary March 24th, 2005
You may find it interesting to know that approximately 15 minutes after sending the second request for Mom's chart, my office received a call from Mr. Owner of the care facility. My secretary informed Mr. Owner that I was out of the office and would return his call later. Mr. Owner got somewhat nasty with her on the phone and then left his number. I was contacted and informed about the situation and decided that it would be best to have my attorney return Mr. Owners call.
My attorney informed me that he had identified himself to Mr. Owner and stated that I had requested him to return the call. When asked the reason for the call Mr. Owner said, Oh nothing, nothing at all.
My Attorney then queried Mr. Owner as to when I could expect to receive Moms chart. Mr. Owners response, "I am taking it under advisement" and hung up. Personally we are wondering what he needs to be advised on since he is legally obliged to provide us with a copy should we request it.
As of this date we have still not received a copy of the documents, even after our Attorney followed up with a written request of his own.
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As you can probably tell by my second request I was getting
somewhat cranky with the care facility
My belief was that the longer the care facility held on to the records, the
greater the chance something, somehow, could become lost or "misplaced"
On October 18th, my attorney received a call from Mr. Owner. This document which resulted from that call
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I find it interesting that when I stopped by the outsourced Pharmacy,
they told me no problem we can just run your Mom's records off. Then they
said that they would have to speak to there Boss. That in turn resulted in
a call to my attorney the next day from Mr. Owner of the care facility. He
apparently had told the pharmacy not to release Mom's records. Which in
turn resulted in the fax item #17. On October 19, 2005 we received the
Pharmacy's response to our request. Item #18.
At the time Mom was admitted to the care center I was out of the country and another family member was with Mom during the move. She arrived in the most clean, up to date care facility we thought we could find. Then spent the most of her first 2 weeks lying in bed, a break-in period we were told. Unsurprisingly to us this left her quite immobile. This was quite concerning to us as our family members had been walking Mom around the hospital unit and she was gaining strength.
Pressure for do not resuscitate….
When I returned, I met with Ms. Social Worker at the facility. She had some additional documents for me to sign. One being a document they called, "Advanced Health Care Directive" I informed Ms. Social Worker that Mom had her own Personal Directive completed for her by our attorney. Ms. Social Worker said they need us to sign one of these as well.
When I returned the next day or so with the signed documents and our addendum Ms. Social Worker was quite concerned that we were following Mom's personal directive which instructed us to ensure that she was full code, to be resuscitated in any situation. The care centers preference was that Mom was to have a DNR (Do Not Resuscitate) order. Although she was very pleasant about it she let me know that this was not something we should honor. (it makes me wonder sometimes, why does the legal profession suggest we get these Personal Directives when the Medical profession tries to get the agent to overturn them just when they are needed?)
Following is a copy of their document and our addendum.
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Time continued to pass and we began to get very concerned regarding Moms condition. We left many messages in a 3-6 week period asking Ms. Dr. to call us. We never received a response.
During this time the facility also wanted us to come in for what they called a "Care Conference" this took awhile to accommodate due to scheduling concerns and honestly those concerns were both on our part and theirs. Finally that conference took place on August 10th, 2005. What was the primary discussion point of our Mothers care conference? The DNR order! Ms. Dr. tried everything she could, including guilt manipulation. "Oh you wouldn’t want to have your Mom go through the process if you knew what would be happening to her"
After asking Ms. Dr. if she was wanting me to breach my fiduciary responsibility in the matter, and getting quite fed up with her line of questions and comments she temporarily moved on.
The facility had no other points to bring up regarding Moms care. Fortunately we did have concerns and used this time to voice them.
Broken promises……
Our family's concerns included rapid weight loss, lack of assistance to drink and Mom's increasing lethargic, listless demeanor. In addition, basic ear care was requested. As far as the hydration problem went I even suggested to the therapist that I had seen people who run with water packs on their backs, and that a straw that came right up to their mouth. Ms. Therapist eagerly responded that she had also seen such things. I said great! Surely there must be some sort of medical equivalent. I offered for them to find what will work best for them and I would pay for it! Nothing was done, evidenced by nothing showing up in her room to do the job.
During this session I personally questioned Ms. Dr. regarding ear care for Mom, mentioning that Moms past GP had done it previously and that it was probably time to do it again. She told me that she would take care of it.
Long story short, none of this was ever followed up on by this "fine" care center.
Incomplete answers…..
Sometime after this meeting, my sister and I were in visiting Mom. We started to brush her hair and discovered a large number of lumps on her head. We asked Mom if they hurt and she said they didn’t. Immediately I went to the nursing desk to see what they were and why they had not contacted us. The staff ran all around asking each other, looking at books, saying they did not know anything about it as they were looking. Finally I suggested some what forcibly, that maybe it would be a good idea just to come down right then and look at them. So they did. The nurse that came down, spent a few minutes looking at them, and told us she had no idea what they were.
We decided to wait a few days and have Ms. Dr. look at them when she came in. Towards the end of the agreed upon day I received a call from the care center. "Mr. Warden, Ms. Dr has looked at the bumps on your Mom’s head and they are old age." I asked, “What do you mean?” "Old age" was again the response. "Yes I know she is old but what are the bumps?" I said. "Old age" was again the response. As one might imagine I was quite irritated by such an answer and said, "Old age? Old age? Would you accept such a diagnosis regarding your dog? What are the bumps?" The caller didn’t know so I found out Ms. Drs regular office phone number and called there. Shortly after I received a call back. Ms. Dr. told me that they were benign cysts that older people sometimes get. She could remove them, but it would be very uncomfortable for Mom. We decided to leave them.
The TV interview…..
On September 8th, 2005 I received a call from a family friend of 30+ years, Ruth Adria. Ruth is well known around the province as an elder advocate and is a very noble lady with a great heart.
http://www.elderadvocates.ca. Ruth told me that she had received a call from CFRN TV News and that a gentleman named Dan Kobe wished to interview someone visiting a loved one in a care center. The individual would then be asked for their opinion on a just released government report on nursing center care. Ruth asked me if she could give Mr. Kobe my name as someone to interview.With much consideration on my part I agreed to the interview. When the news crew and I arrived at the care center we found that Ms. Administrator and Capital Health PR Guy were waiting for us. I went on ahead to see Mom before they came in and to let her know what was going to be happening. To my great surprise I found her sitting up in a chair, hair all done and her best clothes on. The room was immaculate. I informed Mr. Kobe that this is not at all how we would normally find Mom. Normally she would be in a room that smelled pungent of feces, in a fetal position and not very alert. This was quite a change and I wanted him to be aware of the situation. The interview was then done. Please feel free to view it on the media page of this site. Ms. Admin and PR Guy were standing behind, out of camera range, I guess to hear what we were saying. Maybe it was to lend some sort of intimidation factor. From my impression, that’s just what it felt like.
Don’t feed a starving woman…..
The next day September 9th, 2005 Ruth phoned me again. She said that she was going to see Mom at the care center and wondered what kind of food snack she could bring. I laughed and said, "Ruth she really likes doughnuts and ice caps from Tim Horton's. Ruth laughed and told me she would do that.
Later that day I received a call in a very panicky tone from Ms. Admin. She said, "Do you know that Ruth Adria is in here to see your Mom and she is feeding her a doughnut and ice cap? My response was yes! She is an old friend and asked me what she could bring in! But she can’t do that your Moms on a puréed diet; I had to call the Ms. Dr., Capital Health, Mr. Owner and (someone else who I can’t remember.) My response was, "Do you think that when we come in to see her we don’t bring her something? Do you think that if we take her out, we don’t feed her? If we took her home for Christmas dinner would we not get her some food? Leave Ruth alone. She’s doing great."
The last thing I would like to mention about that interview directly was that later on that same day, September 9th, 2005 I received a call from Ms. Social Worker. She told me that they were just happening to be updating their records and they would like me to fax them a copy of Mom's "Enduring Power of Attorney and Personal Directive." I found this interesting due to both timing and in that I had already given this information to them...hmmm Remember what I said about Ms. Admin and PR Guy during the interview...
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I realize that this is getting long…but don’t quit now because this is where it gets more interesting!
A neglected toe turns black….
On September 11th my wife and I visited Mom. She had a bandaged foot. When I queried the staff as to why, they all ran around searching for information. No one knew anything about it! Finally, they told us that they had located information which told them it was a bed sore. The next day, my sister and I unwrapped the bandage ourselves to see the sore. What did we find? A gangrenous toe! Although the care centre suggested we wait 2 or 3 days to see the facility’s doctor, my sister and I had her transported to one of the city’s finest hospitals. The hospital debated whether Mom could even keep her toe or if it needed to be removed.
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Please note pop out by pink arrow saying "4 days" was written by me
Item 6C is a copy of the EMT Report, and is Part 3 of the
care center transfer form.
I find it interesting to note that on 6B the care center nurse (neither named or
signed in the space provided) states no other complaints and it is again backed
up in 6C by her comments. However, this nurse also states that "Left great
toe noted reddened black color, dry and zero drainage. But in 6C the
EMT more accurately describes, "left great toe has black ulcer that has begun to
ooze blood, patient withdraws foot when touched, good pns (?) skin tents on hand
when pinched ( I am told that this is a sign of dehydration)
What is happening here...attention to detail or...
As you can see in this document which was completed at the time of transfer by the care center, the only major problem mentioned was the reddened toe with necrosis. Nothing else major was mentioned . I guess one could gather that other than that she was in pretty good shape. (Remember the care center has so far refused to provided any documents to the contrary) In addition, the document states that this had been going on since September 2nd, 2005. They never mention it to us then, there was no evidence even on the 8th when I was there to do the interview or at any other time. I would have noticed. It is a line I simply don’t believe. This gangrene was progressing extremely fast.
Hospital staff submits report to social services….
Members of the medical team at this hospital told us Mom was suffering from extreme dehydration, extreme malnutrition, and severe infection in her toe and elsewhere. This condition was so bad that by law they were required to submit a report to the Alberta government under the Persons In Protective Custody Act. This complaint and others are currently in the hands of Iris Evens office under investigation. (Hmmm…by the way remember the panic when Ruth was feeding her a doughnut. Panicking about giving starving women a doughnut, great care!)
To add even more concern one of the hospital workers asked us if we knew that the Senior Physician worked in Africa with aids patients? His comment apparently was that he had not seen anyone in North America in that debilitated of condition.
How was this done?
My self and another family member were asked to meet with the hospital unit's Social Worker and the Unit Charge Nurse. They were very concerned in their demeanors and told us of what the medical team had found. They also told us that this team and its lead doctor had asked them to discuss this with us. (because of course nothing would ever be done in a hospital setting without the direction of the lead physician)
Although I was greatly concerned about what they were saying, I was not surprised. You see the toe was just the culminating incident. We were looking for a way that we could extradite Mom from this care center and get her moved into another. We felt that our only hope of doing this quickly was to get Mom into a good acute care center were she could be properly assessed and moved back through the system to a different care center, that is if she wasn’t already so debilitated that she wouldn’t survive in the long term.
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Hospital Social Workers Report Spells It All Out
Thanks!
As you can clearly see this sampling of records
indicate what Moms condition was
Additional Documents have been set aside for possible future use
By the way, as you may recall earlier in this report I told you that during our "Care Conference" with the care center I specifically asked Ms. Dr. to check and clean Mom's ears, and she said she would.
While as you can see in the hospitals Social Workers report, "…A sore on her ear that was oozing pus and took nursing staff ½ hour to clean adequately… More evidence in my opinion that the medical staff and care center staff just didn’t care.
Contagious Pseduomonas infection…….
On the hospital pictures page of this site there is a picture of Mom's toe. You can see that it has been cut short and into the flesh. I have been told by a variety of medical personnel that this type of cut in a care center is an excellent place for an infection called pseudomonas to enter the body. Pseudomonas is a fatal type of infection which was found in Moms urinary bladder by the hospital. (the specimen for this was taken upon entry in the hospital ER)
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It is quite possible from what I have been told that this infection is still being passed around the care center by these same toe clippers. I hope not.
Mom died in hospital on September 23rd from these conditions, as told to me by that same hospital team.
The unanswered question….
So at the end of all of this my question is;
With her death seemingly stemming from neglect from the care center, and in light of the hospital medical team launching an investigation into her care, why then as of this date has there not been a wrongful death investigation by provincial government? So far the only answer I receive from government & hospital staff is "I don’t know." If the circumstances were the same with a child who died while under the care of a government financed institution, I believe things would be different. Please… don’t tell me there is no wrongful death investigation because she was old!
So you say what about this "Persons in Protective Care" investigation?
While the folks that are conducting this investigation seem to be great people and doing their job with determination, their end mandate is only to provide recommendations and even participating in their investigation is voluntary.
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I questioned one of the investigators regarding the fact that there seems to be only recommendations with no consequences. Their reply was that the care centers don’t like the investigation process in itself as if the investigation was punishment enough! I was also told they could have their government financing pulled. This is curious, as the care centre doesn’t even have to participate in the process if they choose not to. When I asked one of the government workers if this government funding has ever been pulled, the answer was, “not to my knowledge.”
