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    Ec083122 Ec083122 Document Transcript

    • Twentieth Annual Report Of theGeriatric and Long Term Care Review Committee Office of the Chief Coroner Province of Ontario September 2010
    • Table of ContentsIntroduction ...........................................................................................................1Methodology and Case Review Process ..............................................................2Recommendations Process ..................................................................................2Geriatric and Long Term Care Review: Committee Activities - 2009 ....................32009 Case Review Summary ...............................................................................4Recommendations from 2009 cases.....................................................................5 Medical / Nursing Management .........................................................................5 Communication and Documentation ..................................................................8 Use of Drugs in the Elderly ................................................................................9 The Acute Care and Long Term Care Industry in Ontario -including the Ministry of Health and Long-Term Care ........................................................................10Summary of Recommendations from Cases Reviewed - 2009...........................13Figure 1 – Percentage of Recommendations Based on Area of Concern - 200914Case Reviews .....................................................................................................15 Case 1 .............................................................................................................15 Case 2 .............................................................................................................17 Case 3 .............................................................................................................22 Case 4 .............................................................................................................29 Case 5 .............................................................................................................34Analysis of Recommendations: 2004 - 2009.......................................................39Acknowledgements.............................................................................................41
    • IntroductionOriginally formed in December 1989, the Geriatric and Long Term Care ReviewCommittee to the Chief Coroner for the Province of Ontario has just completed itstwentieth full year of operation.The Committee membership in 2009 included:Dr. Peter Clark Regional Supervising Coroner, Committee ChairMs. Kathy Kerr Executive LeadDr. Barbara Clive GeriatricianMs. Sheila Driscoll Ministry of Health and Long Term CareDr. Sid Feldman Family PhysicianDr. Margaret Found Family Physician/CoronerDr. Lynne Fulton Emergency Room PhysicianDr. Heather Gilley GeriatricianDr. Barry Goldlist GeriatricianDr. Michael Gordon GeriatricianDr. Jennifer Ingram GeriatricianMs. Margaret Leaver-Power NutritionistMs. Karen Thompson Registered DieticianWhen necessary, health care professionals from other disciplines, includingpsychogeriatrics, gastroenterology and infectious diseases, have assisted theCommittee with case reviews.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 1
    • Methodology and Case Review ProcessGeriatric and long term care cases are referred to the Committee through theRegional Supervising Coroners in the province.The Geriatric and Long Term Care Review Committee conducts an independentreview of the available records relevant to the specific case and prepares a finalreport which may include recommendations aimed towards the prevention of futuredeaths in similar circumstances.Recommendations ProcessThe recommendations suggested by the Geriatric and Long Term Care ReviewCommittee are intended to promote discussion and initiate change. Therecommendations are not to be interpreted as policy directives from any agency orministry of government, including the Office of the Chief Coroner. Therecommendations focus on preventing future similar deaths by building awarenessand recognition of issues affecting the geriatric and long term care communitieswithin Ontario.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 2
    • Geriatric and Long Term Care Review: Committee Activities - 2009In 2009, the Geriatric and Long Term Care Review Committee (GLTCRC) revieweda total of 20 cases which resulted in 39 recommendations. There were 8 casesreviewed that did not result in any recommendations.Members of the GLTCRC participated in the following activities: Regular meetings Regional Coroner’s Reviews Speaking engagements at educational forums Liaison and communication with: a. Individuals b. Government ministries c. Acute and chronic care general and psychiatric hospitals d. Public health departments e. Private industry long term care facilities f. Medical and nursing associations g. Advocacy groups h. Ontario and American Coroners and Medical Examiners i. Chief Coroners from other provinces and territories j. Long term care associations and institutions throughout Canada k. The International Association of Coroners and Medical Examiners l. Various professional gerontological associationsGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 3
    • 2009 Case Review SummaryIn 2009, the Geriatric and Long Term Care Review Committee reviewed a total of20 coroners’ cases that were referred to them involving residents of long term carefacilities and the elderly. Upon reviewing the cases, the committee generated atotal of 39 recommendations aimed at preventing future similar deaths. Theserecommendations focused on issues and concerns relating to: Medical and Nursing Management Communication and Documentation Use of Drugs in the Elderly The Acute Care and Long Term Care Industry in Ontario, including the Ministry of Health and Long Term CareRecommendations were distributed to relevant individuals, facilities, ministries,agencies, special interest groups, health care professionals (and their licensingbodies) and coroners, through the relevant Regional Supervising Coroners.Recommendations were also shared with Chief Coroners and Medical Examiners inother Canadian jurisdictions and to any other individuals or groups upon request.The Geriatric and Long Term Care Review Committee acknowledges that qualitylong term care does exist in Ontario. The deaths reviewed represent only a smallportion of the total number of cases investigated by coroners that involve residentsof long term care facilities and the elderly.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 4
    • Recommendations from 2009 casesThe following recommendations were made after a thorough review of the 20 casesreferred to the Geriatric and Long Term Care Review Committee in 2009. Theserecommendations are not to be interpreted as policy directives. Recommendationsare intended to promote discussion and initiate change. Recommendations focuson the prevention of future similar deaths.Medical / Nursing Management 1. Health care professionals should be reminded that constipation and obstipation are common, preventable, and treatable medical conditions that affect the elderly. Untreated, these conditions can be devastating and may even result in death. Once obstipation is suspected, aggressive investigation and treatment should be considered on a case by case basis. As with many geriatric syndromes, obstipation may present either typically (abdominal pain, fecal incontinence) or atypically (confusion, delirium). Health care professionals should be especially wary of elderly patients who present with constipation/obstipation who have associated systemic symptoms (tachycardia). In these cases, the ordering of laboratory investigations and an EKG should be considered on a case by case basis. The occurrence of overflow incontinence should alert the treating health care professionals to the possibility that the patient has developed fecal impaction with overflow incontinence. Fecal impaction can be difficult to treat and should be treated vigorously when present. Careful abdominal and rectal examination should be performed. The findings of soft stool or no stool in the rectum does not absolutely rule out the presence of fecal impaction. In these cases, an abdominal flat plate xray and/or CT scan should be ordered to rule out the possibility of a higher impaction that cannot be detected on rectal examination and/or a developing acute/subacute bowel obstruction (dilated loops of bowel with air/fluid levels). While manual disimpaction should be the first intervention attempted, the presence of obstipation with a higher impaction should primarily be managed with enemas to clear the bowel from below. In some cases, the addition of oral osmotic laxatives such as Lactulose can be used to clear the bowel from above. Gastrointestinal lavage solutions have also been proven to be very effective in treating fecal impaction. Health care professionals should always be observant for the development of complications related to the treatment of obstipation/fecal impaction. References: Goldlist, B., Gordon, M., Naglie, G. (1992). Constipation can be deadly. Canadian Family Physician. 38, 2419-2421.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 5
    • Mayo Clinic Proceedings. Evaluation and treatment of constipation and fecal impaction in adults. (Review) (12 refs) 73(9):881-6 quiz i887, Sept. 1998. Ortiz-Cmacho, C.M. Mayo Clinic Prather. Institution Gastroenterology Research Unit, Minnesota, U.S.A. 2. Health care professionals should be reminded that disease presentation in the elderly is frequently atypical and may vary greatly from patient to patient. A subtle change in a patient’s clinical status may well indicate that something serious is going on which may not be readily apparent. The underlying cause(s) of these atypical presentations may be missed if the investigator does not obtain an appropriate history, conduct a thorough examination, and judiciously utilize available laboratory and imaging resources. For example, an increase in the number of falls may be due to the development of increasing constipation which, if left untreated, may result in serious morbidity and or mortality. 3. Health care professionals should be reminded that falls in the elderly and especially repeated falls, can have potentially serious outcomes. All acute care and long term care institutions in the Province of Ontario should develop a comprehensive and evidence based falls prevention program which should include, but not be limited to, assessment strategies including a review of the elderly patient’s medication profile, therapeutic intervention and management plans, and prevention strategies. When elderly residents fall, health care staff should communicate this information to the most responsible physician in a timely fashion for the purpose of allowing the physician to assess the resident for the presence of any injury and look for possible precipitating causes for a fall. While not all falls can be prevented, elderly residents who repeatedly fall may require individualized interventions. Even with optimal medical and nursing management, falls may still occur. In these cases, consideration should be given to instituting a “human solution” to preventing falls by arranging for a family member or a hired sitter to be present at the bed side at all times. Note: This recommendation was made in two reviews in 2009. 4. Health care professionals should be reminded that when constipation or other medical issues occur in the elderly and are thought to be due to, or exacerbated by medications, the recommended initial approach should be to discontinue or replace the suspected medication rather than adding additional medications. Reference: Rochon, P. & Gurwitz, J. (1997). Optimizing drug treatment for elderly people: the prescribing cascade. British Medical Journal, 315, 1096-1099.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 6
    • 5. Health care professionals, caring for the elderly should be reminded that pain is one of the most common, treatable symptoms in the elderly. Some of the principles of good geriatric pain management include the following: a. Identification of the cause of the pain; b. Adopting the philosophy of effectively treating the pain; c. Regular, not PRN administration of pain medications, beginning with non- narcotic medications such as Acetaminophen, followed by narcotic medications when, and if, the non-narcotic medications are no longer effective; d. Regular, ongoing, careful assessment of the pain, including titration of the dosage depending on the patient’s response; e. Standardized assessment of the patient’s pain including both typical (i.e. complaints of pain), and atypical (i.e. agitation, loss of appetite), symptoms and signs; f. Utilization of physiotherapists or occupational therapists on alternative positioning in chair or bed to maximize comfort. 6. Health care professionals should be reminded of the importance of physically assessing elderly patients when there is a change in the status of the patient. If a telephone diagnosis is initially made, a follow-up visit to conduct a comprehensive physical assessment should be conducted within a reasonably short period of time. Documentation on the health care record of the elderly patient’s history, physical findings, and proposed therapeutic interventions should be mandatory. 7. Health care professionals caring for intellectually challenged residents with abnormal behaviours should be reminded of the importance of holding regular case conferences to assess risk and safety issues. For example, when these clients are discharged into a community setting, individualized care plans can only be successful if risk and safety issues are identified and addressed. Discussion of the issues with the substitute decision maker will allow for the giving of informed consent required to make decisions balancing the resident’s quality of life and safety risks. 8. Health care professionals should be reminded that a change in the environment for an elderly demented senior may result in the development of abnormal behaviours. Specialized management strategies including more intense supervision and/or pharmacotherapeutic interventions during the first few days in an unfamiliar environment may result in a more satisfactory transition. 9. Health care professionals should be reminded that elderly demented seniors with concomitant cerebral atrophy are at increased risk to develop serious vascular intracranial sequelae as a result of minimal trauma.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 7
    • 10. Health care professionals should be reminded of the importance of ensuring that staff caring for clients with intellectual disabilities in the community setting fully understand the client’s medical issues and their care, safety and supervision needs. 11. Health care professionals should be reminded that Clostridium difficile associated disease (CDAD) has a high morbidity and mortality in the elderly. A high index of suspicion must be maintained in any elderly person with diarrhea. The importance of being aware of all of the significant risk factors for the development of CDAD and of the recommendations to treat presumptively while awaiting results of the investigations cannot be overemphasized. 12. Health care professionals working in the long term care environment should be reminded of the importance of “double checking” technology that may result in a serious health risk if the technology malfunctions. For example, the interruption of the flow of oxygen through an automated delivery system may result in a potentially serious condition. The use of checklists should be encouraged. 13. Health care professionals should be reminded of the importance of following up on previously ordered laboratory and/or diagnostic imaging procedures. 14. Health care professionals should be reminded that urinary catheters are useful in the management of urinary retention and are generally not indicated in the management of fractured ribs. 15. Health care professionals should be reminded that restraints are rarely indicated for the protection of a urinary catheter.Communication and Documentation 1. Health care professionals should be reminded of the importance of keeping complete, comprehensive, and accurate progress notes regarding treatment decisions and assessments. Frequently, the Committee finds these notes to be absent, scanty, incomplete, irrelevant, inaccurate, and/or illegible. These notes should meaningfully reflect issues identified by all members of the health care team (including the family) and include the reason why certain treatments are/are not being done in relation to these issues. Institutions need to develop quality assurance programs in order to determine their level of compliance with these programs and to correct any deficiencies where present. 2. Health care professionals should be reminded that the most responsible physician is responsible for documenting a clear overall care plan as well as discussions with patients if competent, family members, or substitute decision makers regarding the potential benefits and risks of treatment.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 8
    • The physician’s documentation must be timely and appropriate to the complexity of the patient’s clinical status and needs. For example, acute changes in a patient’s clinical condition and the ordering of new medications are appropriate times for the physician to record a note on the health care record. 3. Health care professionals should be reminded of the importance of good communication amongst ALL members of the health care team including family members in situations where a patient’s clinical condition suddenly, unexpectedly, and unexplainably changes, and/or when family members have expressed concerns regarding the patient’s clinical course. The importance of documenting the information communicated, and with whom the communication has occurred, cannot be overemphasized. 4. Health care professionals should be reminded that family members are a vital member of the health care team. Family members’ concerns and observations should be acknowledged, taken seriously, and responded to in a timely fashion. The importance of documenting family interactions reflecting serious concerns cannot be overemphasized. 5. Health care professionals should be reminded of the importance of clearly identifying who the most responsible physician is on a patient’s admission to hospital, ideally on the admission orders. 6. The Committee strongly supports the ongoing development of accessible, electronic health care records documenting the longitudinal nature of the patient care.Use of Drugs in the Elderly 1. Health care professionals should be reminded of the limited indications for the use of Loperamide Hydrochloride in the clinical setting. The first step in managing diarrheal illness, especially in the elderly, should include a comprehensive and thorough clinical assessment following which the clinical diagnosis(es) can be formulated. Fecal impaction with overflow incontinence/diarrhea should always be included in the differential diagnosis. Health care professionals should also be reminded that Loperamide Hydrochloride is absolutely contraindicated in the management of Clostridium difficile associated disease. 2. Health care professionals should be reminded that elderly seniors who are on antiplatelet medications are at increased risk to develop serious vascular intracranial sequelae as a result of minor trauma. In addition, the development of confirmatory diagnostic symptoms and signs may not be readily apparent. Ongoing monitoring for the symptoms and signs of intracranial complications is highly desireable.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 9
    • 3. Health care professionals should be reminded that the use of more than one antiplatelet agent may increase the risk for hemorrhagic complications, especially following a minimal traumatic event. 4. Health care professionals should be reminded of the importance of monitoring medications prescribed in the elderly. Even when medications such as analgesics are required in the elderly, toxic side effects may still occur. 5. Health care professionals should be reminded that Codeine is not a reliable and effective analgesic for end of life care. Morphine Sulfate or Hydromorphone are more effective analgesics. While the initial dosage should be low in most instances, doses may be titrated upwards to ensure adequate pain relief. 6. Health care professionals should be reminded of the importance of adjusting the dosages of medications to obtain an effective, therapeutic outcome (i.e. don’t treat by dose, treat by outcome).The Acute Care and Long Term Care Industry in Ontario -including the Ministry ofHealth and Long-Term Care 1. The MOHLTC must provide more resources to increase staffing in LTC homes. It is clear to the Committee that the “downloading” of increasingly complex residents, who would have been previously housed in Complex Continuing Care facilities or in highly supportive mental health settings, cannot continue without increasing both the number and qualifications of staff in LTC homes. Homes require both more staff, and more qualified staff in order to safely care for the populations in LTC homes in Ontario in the 21st century. 2. The MOHLTC must continue to develop innovative and creative community- based alternatives to LTC homes for younger adults with combined physical, cognitive and psychiatric disabilities. While there is growing availability of community-based services for individuals with psychiatric illness alone, it seems that once physical or cognitive disability arises, the only alternative is LTC. Intensive, ongoing and long-term community-based services must be available as an alternative. 3. The Committee supports the development of models of care to support the clinical management of increasingly frail and medically unstable residents in licensed long term care homes throughout the Province of Ontario. 4. In light of the changing severity and epidemiology of C. difficile, all hospitals in Ontario utilizing preprinted physician orders should ensure that the preprinted order forms are updated regularly to be consistent with current provincial treatment guidelines.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 10
    • 5. All hospitals in the Province of Ontario should develop and utilize a “Medication Reconciliation Plan” to ensure that medications being taken preadmission are continued after admission, if clinically indicated. 6. The Ministry of Health and Long-Term Care should review Ministry guidelines to reflect the reality that licensed long term care homes are being increasingly required to safely manage elderly demented residents with abnormal behaviours. 7. The Ministry of Health and Long-Term Care should take steps to ensure that all licensed long term care homes have adequate resources to prevent aggressive residents from harming other residents and staff. Implicit in this recommendation is the need to ensure that all licensed long term care homes have an adequate and safe physical environment and adequate numbers of suitably trained staff. 8. Licensed long term care homes should be aware of the potential risks of wandering residents in the presence of individuals on supplemental oxygen. 9. Oxygen therapy suppliers servicing long term care environment should be knowledgeable about the potential risks associated within the long term care setting. Consideration should be given to ensuring that the “on/off” toggle switches on oxygen delivery systems are protected. 10. In addition to more staff and more qualified staff, the MOHLTC must support LTC homes with more educational resources to facilitate staff training at all levels, including physicians, in the care of these complex patients. This training must be comprehensive and planned proactively based on needs, and delivered as an ongoing development program, not just as a single episode in reaction to problems. 11. LTC homes should carefully evaluate the placement of younger residents with mental health and behavioural problems, with a particular focus on risk. The MOHLTC should support the development of an additional pre- admission risk-assessment protocol, similar to the current protocols in use for falls risk and skin breakdown risk, to be used in all LTC homes. This protocol will necessarily be more complex and detailed than the aforementioned ones. Where risks are identified, the MOHLTC should fund the LTC home to implement risk-mitigation strategies (e.g. placement in a single room). 12. The MOHLTC and the Community Care Access Centres must recognize the limitations of using the RAI-HC as the pre-admission assessment for LTC home placement. a. The RAI-HC was developed and validated for gathering information regarding elderly (i.e. more than 65 years), frail residents of long-term care settings. It is a useful instrument for describing populations, gathering most important data regardingGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 11
    • disabilities and diagnoses, and for communicating individual care requirements and prognosis. The RAI-HC was not developed and validated for use with a 59 year old homeless man with major mental health problems. This limitation should be recognized, and addressed using recommendation b) below. b. The RAI-HC (Resident Assessment Instrument – Home Care) is an insufficient instrument alone for gathering pre-admission information, and must be supplemented by additional qualitative information. CCACs must be diligent and thorough in gathering information about potential residents especially when there is a history of major mental illness and behavioural problems. This must include, but is not limited to, gathering information from the inter-professional team of clinicians involved, from the community social agencies and workers involved in the relevant past, and family. Of particular importance is the detailed social and behavioural history, in order to identify and mitigate any risks related to anti-social behaviour. The GLTCRC is aware of models in Ontario which facilitate this information exchange, such as “ACL rounds” in hospitals, where inter-professional teams meet with CCAC personnel to share information and collaborate in planning for appropriate LTC home placement. Inter-professional collaboration and communication are essential for the care of complex patients regardless of age and must be part of the assessment process.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 12
    • Summary of Recommendations from Cases Reviewed - 2009Major Issue of Case Number of Cases Number of recommendations (n=20) (n=39)Medical / Nursing Management 7 15 35% 39%Communication and Documentation 3 6 15% 15%Use of Drugs in the Elderly 4 6 20% 15%Acute Care and Long Term Care 6 12Industry, 30% 31%Including the Ministry of Health andLong-Term CareTotal number of cases reviewed 20Total number of recommendations made 39Total number of cases with no 8recommendationsGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 13
    • Figure 1 – Percentage of Recommendations Based on Area of Concern - 2009 Percentage of Recommendations Based on Area of Concern - 2009 Medical / Nursing Management 31% Communication / 39% Documentation Use of Drugs in the Elderly 15% 15% Acute and Long-Term Care Industry (MOHLTC)Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 14
    • Case ReviewsTo help demonstrate the complexity of issues examined by the Geriatric and LongTerm Care Review Committee, 6 of the 20 cases reviewed in 2009 are summarizedbelow. The selected cases demonstrate the comprehensive and thorough reviewand recommendation process undertaken by the Committee, as well as highlightsome of the general themes of concern that are consistent throughout the casesreviewed.Case 1Reference: 2008-6984Issue:Management of an elderly person in the community setting, following dischargefrom a long term care setting.Summary:This is the case of a 57 year old intellectually disabled woman who died in July2008 after being left unsupervised in a bathtub for approximately 10 minutes. Apost mortem was conducted and there was no definitive anatomic or toxicologicalcause of death although the circumstances are consistent with death due todrowning.The woman had resided in an regional centre for individuals with developmentaldisabilities for 32 years - from 1975 until 2007. The centre was scheduled to close,so she was moved to a community living residence in 2007. The closure wasconsistent with a five-year plan that had been announced by the provincialgovernment in 2004, to close three regional centres for individuals withdevelopmental disabilities. The mandate of the initiative was to meet the goals ofthe “Challenges and Opportunities” paper that was written in 1987. The paperdirected that all facility settings for people with development disabilities in theProvince of Ontario would be closed and community based supports would beprovided.A detailed “Transition Plan” for the woman was started well in advance of hertransfer to the community. In June 2005, there were discussions with her familyregarding the subsequent closure and move and although the family were notpleased with the closure of the facility, they requested that the woman be placed ina community in close proximity to their residence.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 15
    • In June 2006, a detailed plan outlining the woman’s care needs was developed withinput from her family and staff from the centre. The plan identified her “likes anddislikes”, as well as “positive rituals or routines requiring assistance.” The plannoted that the woman did not have any knowledge around safety and that sheneeded constant supervision. With respect to bathing, it was identified that thewoman required “hands on support.”In August 2006, a Resident Assessment Instrument (RAI) was done and thewoman was identified as being intellectually disabled. Her cognition was describedas “severely disabled” and she was identified as requiring “extensive assistance”when bathing.In October 2006, a detailed facilities individual support plan was developed for thewoman. The plan included a timetable which identified a daily morning bath.There appeared to be significant planning for the woman’s transition from the centrto the community living residence. The move was viewed as positive by both herfamily and the psychiatrist who had cared for her for many years. Transitiondocumentation identified the woman’s lack of insight into safety requirements andthe need for supervision.The woman had been investigated for excessive daytime drowsiness. Thediagnosis of sleep apnea and narcolepsy could not be made. It was noted that shewas somewhat drowsy and could easily drop off to sleep even while engaged in aconversation. Throughout 2006, the woman was investigated by numerousspecialists because of her syncopal episodes. The consultant neurologist notedthat the “drop attacks” may have been present for four years. The episodes wereoccurring daily while she was standing, sitting, or lying down. She had very briefepisodes of unresponsiveness and recovered spontaneously. She was drowsymuch of the time. On only one occasion was she observed to have convulsivemovements. Her last documented seizure was in 2002.In July 2008, while in the community living residence, the woman was leftunsupervised in the bathtub. It is believed this was done in respect of her privacy,her need for quiet time, and her need for relaxation. It is not clear who made thedecision that she could be left unsupervised in the bath. Previously, in the centre,she had received constant supervision during her bath. The discharge/transferrecommendation specifically referenced the need for constant supervision whilebathing. It could not be determined from the review if the bathing supervision issueGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 16
    • was discussed with the woman’s substitute decision maker. Decisions regardingthe quality of life and safety risks should always be discussed with the substitutedecision maker.Based on the documentation submitted for review, it is unclear whether alternativesafety training or increased qualifications of the community residence staff wouldhave resulted in a more favourable outcome.Recommendations:1. Health care professionals caring for intellectually challenged residents with abnormal behaviours should be reminded of the importance of holding regular case conferences to assess risk and safety issues. For example, when these clients are discharged into a community setting, individualized care plans can only be successful if risk and safety issues are identified and addressed. Discussion of the issues with the substitute decision maker will allow for the giving of informed consent required to make decisions balancing the resident’s quality of life and safety risks.2. Health care professionals should be reminded of the importance of ensuring that staff caring for clients with intellectual disabilities in the community setting fully understand the client’s medical issues and their care, safety and supervision needs.Case 2Reference 2008-735Issue:Management of an elderly person in the acute care setting after a fall.Summary:This is the case of an 89 year old woman who resided alone in the community.According to her family, the woman was able to care for herself and still walked twomiles daily.About two months prior to her admission to the community general hospital (GH),the woman developed visual loss in her right eye. High dose Prednisone therapy(80 mg/day) was initiated which was reduced to 40 mg/day at the time of herGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 17
    • admission. Her other past medical diagnoses included osteoporosis, hypertensionand mild, chronic anemia.On February 29, 2008, the woman presented to the emergency room (ER) of theGH with mild ataxia, generalized weakness, and episodes of confusion.Medications being taken at this time included: Hydrochlorothiazide, Irbesartan,Alendronate Sodium, Rosuvastatin, Calcium, Fosavance, Prednisone, andRanitidine Hydrochloride.The ER note commented on the presence of increasing confusion, disorientation,memory loss and decreased ability to perform activities of daily living (ADLs). Onexamination, there was mild global weakness in the absence of focal neurologicalfindings and the woman required assistance to walk. Initial laboratoryinvestigations revealed a hemoglobin of 105 and a sodium of 124. Thehyponatremia rapidly resolved with the stopping of Hydrochlorothiazide. Her gaitimproved, however the confusion continued. A CT scan of the brain revealedatrophy, small vessel ischemic disease and probable basal ganglia lacunar infarcts.An occupational therapy (OT) assessment revealed that the woman exhibited poorattention when performing tasks, including her ADLs. She was completely unsafewith meal preparation. Her Mimi Mental Status Examination (MMSE) score was16/30. During hospitalization, her cognitive function did not improve so the initialplan of discharge to her home was changed to discharge home with her daughter.The backup plan was discharge to a licensed long term care home (LTCH).During the hospitalization, the woman’s blood sugars were noted to be elevated.This was controlled using low dose Glyburide. Her erythrocyte sedimentation rate(ESR) was monitored and the dosage of Prednisone was decreased slightly. Hermobility rapidly returned to her baseline, so no physiotherapy was required. TheOccupational Therapist continued to monitor the woman’s progress.Both before and after transfer to the Alternative Level of Care (ALC) ward, thewoman had recurrent episodes of chest pain which contributed to the developmentof anxiety. Lorazepam was infrequently administered to control the anxiety. Herdaughter advised that the episodes of chest pain were long standing and thatprevious investigations had been negative. Numerous electrocardiograms andtroponins were reported to be negative. Glyceryl Trinitrate Spray andgastrointestinal medications were given resulting in a variable response to the chestpain. A firm diagnosis was never established.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 18
    • The daughter expressed concern about her mother’s poor intake in April 2008. Thewoman’s indices of dehydration (i.e. creatinine and blood urea nitrogen), weremonitored and did not increase until the terminal events occurred.On April 14, 2008, the woman was assessed by the nurse practitioner. Laboratoryinvestigations revealed a white blood count (WBC) of 17.9 with a neutrophil countof 15.6. A urine culture was ordered.On April 15, 2008, the woman complained of headaches. It was noted that herintermittent confusion continued.On April 16, 2008, her WBC had dropped to 12.3, which was within her usualrange.On April 18, 2008, the hospitalist noted that the woman was afebrile and had nodysuria. Antibiotics were not ordered as the urine culture was reported to be onlygrowing mixed culture. A repeat urine culture was ordered. On April 21, 2008, thehospitalist noted no new findings.On April 23, 2008, the woman complained of a sore throat. Examination of herchest was negative. A throat swab was taken and was eventually reported to benegative. Her urine culture was reported to be positive and Ciprofloxacin wasprescribed.On April 25, 2008, plans were made to discharge the woman to her daughter’shome with Community Care Access Centre (CCAC) support and a backup plan foradmission to a LTCH, if necessary. At 1745 hours, the woman had an episode ofchest pain which was relieved with Glyceryl Trinitrate Spray. At 1810 hours, thewoman fell. Nursing staff were alerted by another resident and responded. Thewoman was found on the floor outside the bathroom. On examination, she had askin abrasion on the left side of her head above the eye. The wound was cleansedand the woman’s physician and daughter were notified. Nursing staff documentedthat the woman’s pupils reacted normally and that she was responding normally.The decision was made to keep her close to the nursing station for observation.At 0915 hours on April 26, 2008, the woman complained of a new chest pain thatwas aggravated by breathing and on palpation. Nursing staff noted that she wasrestless and uncomfortable. Acetaminophen was given for pain control andLorazepam for the associated anxiety. Investigations ordered included a CT scanGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 19
    • of her head and insertion of a Foley catheter with the taking of a urine culture. Shecontinued to complain that the pain was not relieved by the Acetaminophen.On April 27, 2008, nursing staff noted the presence of extensive bruising over herchest wall and coccyx. She continued to complain of unrelieved pain.At 0130 hours on April 28, 2008, the woman tried to get up and her Foley catheterwas stretched. A lap belt restraint was applied. Later that day, the CT scan of herhead was reported to show no new changes and the urine culture was reported tobe negative. On examination, crackles were now noted to be present in the rightlung base. Acetaminophen continued to be given for pain. Overnight, shecontinued to complain of pain which was not relieved by Acetaminophen. Althoughthe woman was in agony, the nursing plan was to wait until the morning to requesta more effective analgesic.At 0935 hours on April 29, 2008, the woman had a chest X-ray that revealed thepresence of fractured ribs. Her WBC, urea and creatinine were reported to be inthe normal range. Morphine Sulfate was prescribed to control the pain.On April 30, 2008, nursing staff noted that the Morphine Sulfate was effective incontrolling the woman’s pain and her daughter consented to the application ofrestraints to prevent unsupervised wandering. Over the next two days, nursing staffreported that the woman’s pain was not always relieved by the Morphine Sulfateand Lorazepam.On May 2, 2008, the woman was kept in a gerichair with a restraint jacket.On May 3, 2008, the woman’s WBC had increased to 21,400 and her creatininewas increased to 133. The daughter called later that day to express concernsregarding her mother’s care, particularly with the lack of oral fluid intake. Shestated that she could not take her mother home in this condition and requested aconference. She also stated that she would like to speak with a physician.Later that day, nursing staff found the woman on the floor outside the bathroomwith her pants halfway down and stool on her buttocks. Her glasses were brokenand she was bleeding from a head wound. Nursing staff put her on a stretcher totake her down to the ER. Apparently, an ER staff person told the ALC nursing staffnot to bring her down to the ER but rather to call the hospitalist. The hospitalist wascontacted, but did not initially respond. Eventually, the hospitalist responded onGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 20
    • May 4, 2008, at which time Hydromorphone and Quetiapine Fumarate wereordered. Nursing staff noted that the woman’s blood pressure remained low andshe required Oxygen to maintain her saturation. The woman’s daughter had adifficult time getting in contact and communicating with the hospitalist.At 2230 hours, the on-call physician called the daughter as the woman’s clinicalstatus continued to deteriorate. She was too drowsy to eat her dinner and herWBC was 38,400, Blood Urea Nitrogen (BUN) was 19.5, and creatinine was 281.Following the discussion, it was decided that no ICU admission was warranted andintravenous fluids and antibiotics would be administered. Attempts were made toarrange a transfer to an acute care bed in the hospital, but there were no bedsavailable.The woman’s clinical condition continued to deteriorate overnight. Shesubsequently died the following day at 1445 hours.A post mortem was conducted and the cause of death was noted as: “Complex and multifactorial in a patient with severe atherosclerosis with 85% occlusion of the left coronary artery, severe mitral valve calcification, urinary tract infection in the presence of renal failure, hypertension, cerebral ischemia and atrophy, and Prednisone induced diabetes mellitus secondary to the treatment of temporal arteritis.”A number of questions were raised by the family regarding the quality of careprovided to the woman following her fall. In particular, concerns were identified withthe pain management procedure utilized, the lack of communication betweenhealthcare providers and the family, the use of restraints and the use of urinarycatheters.Recommendations:1. Health care professionals should be reminded of the importance of good communication amongst ALL members of the health care team including family members in situations where a patient’s clinical condition suddenly, unexpectedly, and unexplainably changes, and/or when family members have expressed concerns regarding the patient’s clinical course. The importance of documenting the information communicated, and with whom the communication has occurred, cannot be overemphasized.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 21
    • 2. Health care professionals should be reminded that family members are a vital member of the health care team. Family members’ concerns and observations should be acknowledged, taken seriously, and responded to in a timely fashion. The importance of documenting family interactions reflecting serious concerns cannot be overemphasized.3. Health care professionals caring for the elderly should be reminded that pain is one of the most common, treatable symptoms in the elderly. Some of the principles of good geriatric pain management include the following: a. Identification of the cause of the pain, b. Adopting the philosophy of effectively treating the pain, c. Regular, not PRN administration of pain medications, beginning with non- narcotic medications such as Acetaminophen, followed by narcotic medications when, and if, the non-narcotic medications are no longer effective, d. Regular, ongoing, careful assessment of the pain, including tritration of the dosage depending on the patient’s response, e. Standardized assessment of the patient’s pain including both typical (complaints of pain), and atypical (agitation, loss of appetite), symptoms and signs, f. Utilization of physiotherapists or occupational therapist on alternative positioning in chair or bed to maximize comfort.4. Health care professionals should be reminded that urinary catheters are useful in the management of urinary retention and are generally not indicated in the management of fractured ribs.5. Health care professionals should be reminded that restraints are rarely indicated for the protection of an urinary catheter.Case 3Reference 2007-673Issue:Placement and management of the elderly with abnormal behaviours in the longterm care setting.History:The deceased was a 59 year old male resident of a Ministry of Health and LongTerm Care (MOHLTC) licensed Long Term Care Home (LTCH).Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 22
    • Significant items in the deceased’s medical history included a developmental delay(reportedly due to traumatic/anoxic brain injury at age 2), personality disorder,seizure disorder (grand-mal tonic-clonic seizures that began in his teens, controlledon anti-convulsant medications) and hearing loss (requiring amplification oftelevision/radio).The deceased lived with Community Living for most of his adult life. He moved intoan independent apartment by himself approximately 7 years prior to his death andwas supported by services provided through the local Community Service Centre.These services included daily supervision and assistance with meals, dressing andbathing, homemaking assistance and a Social Worker who would assist him withinstrumental activities of daily living (ADL), like shopping and banking.Since the death of his mother in 2001, the deceased began to have more difficultycaring for himself in the community. He was not eating properly and began to loseweight, was not attending to his personal hygiene or clothing, and his apartment fellinto disarray. He became known to police due to many calls over this time period.He complained about people watching him and things being stolen from hisapartment. He was investigated for calls related to noise, unusual behaviour andallegations of sexual assault. He was never charged with any offence.The deceased’s family and social worker discussed long term care placement withhim and he agreed to apply, presumably so that he would be in a more supportivesetting that could meet his needs.The Community Care Access Centre (CCAC) assessment for long term care wascompleted in January 2005. He was noted to have had recent significant weightloss, hearing impairment and some cognitive impairment. It was noted that hismood had become worse over the prior three months, and he had been expressingfeelings of loneliness, unrealistic fears and had withdrawn from social and otheractivities. He required full assistance with meal preparation, housework, finances,managing medications, shopping and arranging transportation. He would not eatunless his meal was prepared and set out for him. He required supervision fordressing, personal hygiene and bathing, and limited hands on assistance witheating. He was independent in all other activities of daily living, and was continent.The deceased was offered, accepted and moved into a local, 288-bed LTCH inFebruary, 2005.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 23
    • In August 2005, another resident was admitted from the regional acute carehospital to the LTCH, into the same room as the deceased. The new resident wasa 55 year old man with chronic schizophrenia and evidence of psychopathicpersonality disorder. He had a longstanding cognitive impairment, poor memoryand often did not comply with his medication. He had admissions to manypsychiatric hospitals in this province with no long term resolution due partly to hispersonality disorder affecting the acquisition of insight into his psychiatric illness.The new resident had a significant criminal record for property offences, but wasnot known to be violent. He did not have any previous behavioural issues withformer roommates or staff.In September 2006, the resident’s medications were changed as he was felt to betoo sedated. Following the change in medication, his behaviour and agitationworsened. Several verbal outbursts towards staff were documented. In October2006, the record notes the first specifically expressed complaint about hisroommate, the deceased. In December 2006, an episode of physical aggressionwas noted when he threw a wheelchair into the elevator. There was no aggressiondirected at staff or another person.In December 2006 through January 2007, the resident expressed suicidal ideationand was continually supervised by staff. The resident’s roommate (the deceased),teased the resident about the level of care he was receiving.Mood and behaviour charting were included in the routine charting completed byhealth care aids for both residents. The charts indicated the frequency (but notseverity) of certain behaviours. Accuracy of the behaviour charting is questionablehowever as many events noted in other written records were not reflected in thecharts. There are several references in the records to loud verbal conflicts betweenthe two roommates. Reports indicated that both men initiated the verbalaltercations. Witness statements indicate that most of the verbal conflict consistedof the men insulting each other. Most of these witness statements indicated thatthe conflict happened increasingly in the latter part of 2006.In October 2006, a health care aide reported that he had to intervene when theresident was hitting the deceased during an altercation.In January, 2007, there was a physical altercation between the resident and thedeceased. The fight was over the volume of the deceased’s television. Theresident struck the deceased with his fists and knocked him to the floor. A nurseGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 24
    • witnessed the incident and intervened. The deceased was not breathing and hadno vital signs. CPR was commenced and police and ambulance were called.The deceased was taken to the local general hospital. At the time of arrival, he wascomatose, was not moving spontaneously, did not withdraw to pain, his pupils werefixed and dilated, there were no corneal reflexes, and he had a Glasgow ComaScale of 2+2. He was resuscitated and a heart rhythm and adequate bloodpressure established.A CT scan from the Emergency Room showed no bony fractures, and no scalp orsoft tissue swelling. There was a massive degree of subarachnoid bloodthroughout the basal cisterns and both convexity sulci. Blood was noted in both thethird and fourth ventricles, as well as the trigone of the right lateral ventricle.The deceased was admitted to the intensive care unit of the hospital. A CT scanthe following day showed diffuse cerebral edema and more blood in the rightventricle. A CT angiography showed a large aneurysm measuring 11 mm arisingfrom the origin of the left posterior inferior cerebellar artery. There wasdevelopmental hypoplasia of the right vertebral artery.Later that day, the deceased was declared brain dead and was removed from lifesupport.A post mortem examination was done and the cause of death was noted as, “acutetraumatic rupture of the left vertebral artery complicating blunt impact to the headand neck.”A subsequent MOHLTC “Unusual Occurrence” investigation at the LTC home foundno evidence of unmet standards in the care of either the resident or the decedent.DiscussionThis case raises several issues including: the placement of adults withdevelopmental disabilities in, and within LTCH; placement of adults with severepsychiatric illness in, and within, LTCH; management of behaviours from a varietyof conditions in LTCH; staff training and risk assessment for physical aggression ina resident.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 25
    • Placement of Adults with Developmental Disabilities in LTC HomesThis has been addressed by the Ministry of Health and Long Term Care(MOHLTC), the Ministry of Community and Social Services (MCCS), and anadvocacy group called “The Ontario Partnership for Aging and DevelopmentalDisabilities” (www.opadd.on.ca). There is an extensive protocol, developed by theMOHLTC and MCSS entitled Long Term Care Home Access Protocol for Adultswith a Developmental Disability (July 2006). The protocoal describes in detail, theprocess for placement of adults with a developmental disability in LTC, includingthe additional supports and care planning for the individual. However, thedocument does not address the issue of case mix, or room sharing/geographicplacement within the home for these individuals, except in the case where a largenumber of these individuals are moving together to a LTCH.This protocol was not in place when the decedent was placed in LTC.Regarding the placement of older adults with mental health problems into LTCH,there is a significant lack of specialized services to support the residents and staffof LTCH in dealing with mental illness.In November 2007 the Canadian Mental Health Association – Ontario branch,stated in their newsletter that, “beyond the issue of bed availability, one of the firstchallenges in finding appropriate long-term care for older adults with a mentalillness is the admission process. CCACs are not guided by a mental healthmandate.” People are admitted for a variety of reasons, but an individuals mentalillness is very often secondary. Placement is not based on their mental health, buton their physical mobility issues, other than in the case of dementia. Most LTCHare designed for people who are physically immobile and not for those with amental illness.There are a number of initiatives sponsored by the MOHLTC to address the issueof specialized psychiatric services in LTC. These resources however, remainscarce and almost exclusively focused on dementia.The RAI-HC (Resident Assessment Instrument – Home Care), the instrument usedto gather pre-admission information, is a quantitative data template that allowsspace for qualitative (i.e. narrative) data. The RAI-HC completed on the residentprior to admission was relatively sparse. It is unclear whether the LTCH was awareof the offending resident’s full social history, including his anti-social behaviour andpossible psychopathic personality disorder.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 26
    • The nature and complexity of human health conditions, in particular mental healthand behavioural problems, precludes all necessary information being gathered on astandardized quantitative assessment like the MDS-RAI (Minimum Data Set –Resident Assessment Instrument). Even a fully completed RAI-HC is integratedwith thorough information from sources such as the clinicians caring for thepotential resident, and community-social supports who may know the person well.Information about the resident’s long history of mental health and behaviouralproblems may have changed the decision-making of the LTCH in assessingsuitability for admission, and room assignment.Case Mix in Long Term HomesStaff in LTCHs are now being asked to care for individuals with a wide range ofhealth problems. These include the frail elderly, persons with dementia, acquiredbrain injury, psychiatric illness, developmental disabilities, and persons with severephysical illnesses including advanced neurodegenerative diseases. The MOHLTChas closed over 50% of the hospital-based Complex Continuing Care (CCC) bedsin the province over the last decade or so. These beds were staffed byprofessional nurses in staffing ratios that allowed for safe and effective care ofresidents with complex needs, including advanced disability and mentalhealth/behavioural problems. Now, these residents are in LTC homes, where thenursing and personal care staff are mostly unregulated, and where staffing ratiosare much lower than in CCC. While LTCH in large urban centers can, to a certainextent, “specialize” in certain populations, allowing staff to develop expertise andexperience with a particular population, this is not possible in smaller urban or ruralcenters without moving the individual far from their home community and/or family.Given the staffing of LTCH, staff cannot possibly become experienced andcompetent in caring for the wide variety and complexity of conditions currentlybeing seen in LTCH, especially when many require widely differing managementstrategies.It is not clear from the records whether the staff in this particular LTCH received anyspecial training in managing psychiatric illness and behaviours, or adults withdevelopmental disabilities. Staff may have been more alert to the signs ofworsening psychiatric illness, been better able to assess and manage risk andbehaviours of both the decedent and the offending resident. Physicians shouldalso be included in training initiatives and they should be supported in developingspecific competencies to care for the diverse populations in LTCHs.LTCH residents are over age 18, with widely differing diagnoses. Based on theirhistory and diagnoses, some residents may not be compatible house orGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 27
    • roommates. In this case, a resident with a history of anti-social behaviour and pooranger management, was placed with a vulnerable developmentally delayedresident who seemed to have little ability to understand and appreciate the effectsof his behaviour. It is not clear how much information the LTCH received fromCCAC regarding the prior history of anti-social behaviour of the resident.Alternatives to LTC for adults with psychiatric illness or developmental disabilitiesAlternatives to LTC for adults with psychiatric and/or developmental disabilities arelimited. In many cases, the care required for these individuals exceeds the minimalpublicly funded services available in the community.Recommendations:1. The MOHLTC must provide more resources to increase staffing in LTCHs. It is clear to the Committee that the “downloading” of increasingly complex residents, who would previously been housed in Complex Continuing Care facilities or in highly supportive mental health settings, cannot continue without increasing both the number and qualifications of staff in LTCH. Homes require both more staff, and more qualified staff in order to safely care for the populations in LTC homes in Ontario in the 21st century.2. The MOHLTC and the Community Care Access Centres must recognize the limitations of using the RAI-HC as the pre-admission assessment for LTC home placement. a. The RAI-HC was developed and validated for gathering information regarding elderly (more than 65 years), frail residents of long-term care settings. It is a useful instrument for describing populations, gathering most important data regarding disabilities and diagnoses, and for communicating individual care requirements and prognosis. The RAI-HC was not developed and validated for use with a 59 year old homeless man with major mental health problems. This limitation should be recognized, and addressed using recommendation b) below. b. The RAI-HC (Resident Assessment Instrument – Home Care) is an insufficient instrument alone for gathering pre-admission information, and must be supplemented by additional qualitative information. CCACs must be diligent and thorough in gathering information about potential residents especially when there is a history of major mental illness and behavioural problems. This must include, but is not limited to, gathering information from the inter-professional team of clinicians involved, from the community social agencies and workers involved inGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 28
    • the relevant past, and family. Of particular importance is the detailed social and behavioural history, in order to identify and mitigate any risks related to anti-social behaviour. The GLTCRC is aware of models in Ontario which facilitate this information exchange, such as “ALC rounds” in hospitals, where inter-professional teams meet with CCAC personnel to share information and collaborate in planning for appropriate LTC home placement. Inter-professional collaboration and communication are essential for the care of complex patients regardless of age and must be part of the assessment process.3. LTCHs should carefully evaluate the placement of younger residents with mental health and behavioural problems, with a particular focus on risk. The MOHLTC should support the development of an additional pre-admission risk- assessment protocol, similar to the current protocols in use for falls risk and skin breakdown risk, to be used in all LTCHs. This protocol will necessarily be more complex and detailed than the aforementioned ones. Where risks are identified, the MOHLTC should fund the LTCHs to implement risk-mitigation strategies, for example in a single room.4. The MOHLTC must continue to develop innovative and creative community- based alternatives to LTCHs for younger adults with combined physical, cognitive and psychiatric disabilities. While there is growing availability of community-based services for individuals with psychiatric illness alone, it seems that once physical or cognitive disability arises, the only alternative is LTC. Intensive, ongoing and long-term community-based services must be available as an alternative.5. In addition, to more qualified staff, the MOHLTC must support LTCHs with more educational resources to facilitate staff training at all levels, including physicians, in the care of these complex patients. This training must be comprehensive and planned proactively based on needs, and delivered as an ongoing development program, not just as a single episode in reaction to problems.Case 4Reference: 2008-14016Issue:Management of complications of a fractured hip.HistoryThis is the case of a 77 year old woman who resided with her husband andreceived support services from the Community Care Access Centre (CCAC). Shehad chronic unsteadiness of her gait and used a walker. She required assistanceGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 29
    • for personal care. Her significant past medical history included Parkinson’sdisease, degenerative disc disease, osteoporosis, and small cerebral aneurysms.On September 24, 2008 while bathing with an assistant present, she fell andsuffered an intertrochanteric right hip fracture. She was taken to a General Hospital,then transferred to a Regional Hospital where the hip was surgically repaired. Shewas given appropriate antibiotic prophylaxis and deep venous thrombosisprophylaxis. Her postoperative clinical course was uneventful. She wastransferred back to the General Hospital on September 29, 2008 for rehabilitation.On November 1, 2008, she was transferred to a long term care home (LTCH) forfurther mobilization. Functionally, she required assistance for transfers, used awheelchair for ambulation, required assistance for personal care, but was able tofeed herself.Diarrhea was apparently first noted at this LTCH on November 1. It would appearthat the diarrhea was initially thought to be due to the Iron replacement medicationthat she was taking.On November 2, 2008, a Continence Assessment Tool made no mention of thediarrhea. The record indicated that the woman was continent of both bowel andbladder. This observation was in conflict with information provided by the woman’sfamily.The record indicates that the woman was incontinent of loose, black, watery stoolon November 2 and 3.She was assessed by the LTCH attending physician on November 3. Thephysician acknowledged the presence of diarrhea, as well as the administration ofiron. Further examination revealed the presence of a soft abdomen with notenderness and no bruits. Further treatment was not recommended at this time.On November 5, the woman complained to the Admissions Coordinator about herstomach trouble and diarrhea and requested to see a physician. Progress notesindicated that staff thought the medications were causing the diarrhea. Iron therapycontinued and Acetaminophen with Codiene 15 mg was occasionally being givenfor pain. Vital signs indicated that the woman’s blood pressure was decreasing andpulse and temperature were increasing.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 30
    • On November 6, 2008, nursing staff noted that the woman was very weak, refusedto get up, and had a further loose, black stool. Her BP was 80/50. She wasassessed by the regular house physician who noted that the woman’s husbandstated that she had a bout of diarrhea about one month earlier, but this hadresolved spontaneously. The physician recommended transfer to the emergencyroom (ER) for treatment of the dehydration and that stools for C. difficile culture beobtained upon her return as he suspected the presence of an infectious colitis.Upon arrival in the Emergency Room (ER) of General Hospital 2, the woman wasassessed by an internist as well as by the ER physician. The medical recordacknowledged the presence of two weeks of loose, black greenish offensive stoolsabout twice daily. She complained of nausea, poor appetite, but no abdominalpain. She also noted the presence of a sore throat over the past week, thick urine,frequency of urination but no burning. The ER physician noted “no recent antibioticuse.” Examination of her abdomen revealed right lower quadrant tenderness withsome rebound, left upper quadrant tenderness, no organomegaly, and thepresence of bowel sounds. On rectal examination, “no constipation” was noted.Treatment included the commencement of intravenous Ciprofloxacin for apresumed urinary tract infection. She was placed in isolation because of thediarrhea.On the morning of November 7, 2008, the woman’s clinical status remained pooralthough she was noted to be afebrile. It was noted that treatment with a bolus ofNormal Saline had resulted in an improvement in her BP. Her heart rate remainedelevated at about 135. Over the course of the day, her heart rate dropped down tothe 40-50 range. A CT scan of the woman’s abdomen revealed the presence ofdegenerative disc disease and thickening of the left colon and sigmoid raising thequestion of an infective or ischemic colitis. She was assessed by an infectiousdiseases consultant who recommended continuing the Ciprofloxacin for three moredays and starting Metronidazole in accordance with the C. difficile colitis protocol.The first dose of intravenous Metronidazole was given at 2100 hours on November7. She was continued on the intravenous Ciprofloxacin.The woman died at 0025 hours on November 8, 2008 respecting her “Do NotResuscitate” order.Based on the documentation submitted for review, it is believed that the woman’sdeath was due to sepsis complicating the fractured right hip. No autopsy wasGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 31
    • performed. It could not be determined if the sepsis was due to a possible urinarytract infection or from C. difficile colitis. It is believed that both urosepsis and C.difficile colitis were contributing factors in the death.Even if the C. difficile colitis had been recognized earlier in the course of thewoman’s illness, it is not certain that a more favourable outcome would haveresulted. Thirty day mortality rates for C. difficile vary widely from 4.7% in 1991/92to as high as 23% in the hypervirulent strain initially seen in Quebec, but which isnot the predominant circulating strain in Ontario. Mortality rates are stronglyinfluenced by age and comorbidities. 1Clostridium difficile is the most common cause of hospital acquired diarrhea inindustrialized countries. 2 From the documentation submitted for review, the treatinghealth care professionals may not have been sufficiently aware that the woman wasat very high risk (i.e. had multiple risk factors) for the development of ClostridiumDifficile Associated Disease (CDAD). The risk factors for the development ofCDAD have changed significantly over the last 10-15 years. In addition to the riskposed to the use of antibiotics, other equally important risk factors include:advanced age, use of proton pump (PPI) medications, recent hospitalization orresiding in a LTCH, and systemic chronic illness. In this particular case, thewoman’s recent hospitalization, use of a PPI, and advanced age should have beenreason enough to place CDAD high on the list of possible diagnoses. In addition,knowledge of her prior antibiotic therapy at the time of her hip surgery may haveraised the level of suspicion for the presence of CDAD.It appears that the woman had an acute change in her bowel habits at the time ofher transfer from the General Hospital to the LTCH. A cumulative medication recordmay have been helpful in this case. Currently, the province is making progress inmedication reconciliation and this appeared to be effectively carried out during thewoman’s multiple transfers. Unfortunately, this process does not documentmedications received previously. The availability of a regionally accessibleelectronic health record may have been helpful.Also of concern was a telephone order that was given for LoperamideHydrochloride for the woman’s diarrheal symptoms. This was given in the absence1 Eggertson L, (2006). Quebec strain of C. Difficile in 7 provinces. CMAJ. 174(5):607-8.2 Bartlett J.G. (2002). Clinical practice. Antibiotic-associated diarrhea. N Engl J. Med 346(5), 334-9.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 32
    • of an etiological diagnosis for the diarrhea. Loperamide Hydrochloride should onlybe used after the cause of the diarrhea has been established and a treatment planhas been instituted. Loperamide Hydrochloride is known to worsen CDAD and mayincrease mortality. 3When the physician assessed the woman on November 6, 2008, the severity of thesituation was recognized and the possibility of C. difficile colitis was acknowledged.In Ontario, the current model of care does not financially support frequent physicianvisits to LTCHs. Models of care that recognize the increasing activity of illness inresidents of LTC homes and allows for frequent and timely evaluations of thechanging health status of the ill elderly residing in LTCHs in Ontario, should beconsidered.Recommendations1. Health care professionals should be reminded that Clostridium difficile associated disease (CDAD) has a high morbidity and mortality in the elderly. A high index of suspicion must be maintained in any elderly person with diarrhea. The importance of being aware of all of the significant risk factors for the development of CDAD and o the recommendations to treat presumptively while awaiting results of the investigations cannot be overemphasized.2. Health care professionals should be reminded of the limited indications for the use of Loperamide Hydrochloride in the clinical setting. The first step in managing diarrheal illness, especially in the elderly, should include a comprehensive and thorough clinical assessment following which the clinical diagnosis(es) can be formulated. Fecal impaction with overflow incontinence/diarrhea should always be included in the differential diagnosis. Health care professionals should also be reminded that Loperamide Hydrochloride is absolutely contraindicated in the management of Clostridium difficile associated disease.3. The Committee strongly supports the ongoing development of accessible, electronic health care records documenting the longitudinal nature of patient care.4. The Committee supports the development of models of care to support the clinical management of increasingly frail and medically unstable residents in licensed long term care homes throughout the Province of Ontario.3 Kato H. (2008). Inappropriate use of loperamide worsens Clostridium Difficile-associated diarrhea.J Hosp infect. 70(2), 194-5.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 33
    • Case 5Reference: 2008-7307Issue:Management of constipation in an elderly resident in the long term care setting.History:This is the case of a 63 year old man who was admitted to a LTCH in May 2008from a residential facility for people with a acquired brain injuries.In 1987, the man suffered a head injury that prevented him from continuing full timework. In 2000, he was hit by a motor vehicle and suffered massive traumaticinjuries, including a severe brain injury. He required a prolonged hospitalizationand subsequent rehabilitation, but was left with significant cognitive and mobilityimpairment and was doubly incontinent. Other significant past medical diagnosesincluded: childhood hip surgery with postoperative osteomyelitis; type IIdiabetes mellitus; chronic anemia; seizure disorder (post motor vehicle accident)and cardiovascular disease.In May 2008, the man was admitted to the LTCH where it was noted that he wasdoubly incontinent, had significant cognitive impairment, and was mobility impaired.He required supervision with transfers and walked with a walker. He appeared toeat well and participated in activities.Throughout his stay in the LTCH, nursing staff noted that the man had episodes ofverbal and physical aggression, often when care was being provided. Firm verbalcommunication was usually sufficient to effect control.In July 2008, the man was noted to have three falls, one of which may have beenassociated with a seizure.In September 2008, nursing staff noted that the man displayed aggressivebehaviour when personal care was being given.In December 2008, nursing staff noted that the man’s falls were becoming morefrequent and in March 2009, the man pushed another resident in the LTCH.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 34
    • In April 2009, nursing staff noted that the man was constipated.In May 2009, the man had an annual physical examination. There were noabnormal abdominal findings documented. A rectal examination was not performedat the time of this examination, nor had one been done the year before when hewas admitted to the LTCH.In June 2009, it was noted that the man had loose bowel movements overnight andthen again the next day. His laxative medications were held. The man’s weight haddecreased by 2.5 kg. Also at that time, progress notes began to be typed,presumably due to a change to electronic record keeping.In July 2009, nursing staff noted that the man was having frequent falls and hisabdomen was extremely distended. When questioned by staff, he advised that hehad not had any recent bowel movements. He was given Bisacodyl suppository,then had breakfast. Nursing staff contacted the attending physician whorecommended transfer to hospital for assessment.The man arrested as the ambulance arrived and could not be resuscitated.A post mortem examination was performed and it was determined that death wasdue to acute small bowel infarction as a result of large and small bowel obstructionfrom fecal impaction in a man with a remote brain injury (motor vehicle collision)and significant atherosclerotic coronary artery disease involving the left anteriordescending coronary artery.DiscussionThe Geriatric and Long Term Care Committee continues to see cases whereconstipation has resulted in the death of an elderly person. This trend is especiallytroublesome given the fact that deaths continue to occur subsequent to thepublication of the article “Constipation Can Be Deadly” in Volume 38 of theCanadian Family Physician in 1992.This man suffered from chronic constipation throughout his stay in the LTCH. Fromthe documentation submitted for review, it would appear that a rectal examinationwas not done on admission, or at the time of his yearly physical examination in May2009. When he developed loose bowel movements in June 2009, his laxativesGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 35
    • were held and again, a rectal examination was not performed. Had a rectalexamination been done in May or June 2009, the diagnosis of fecal impaction withoverflow incontinence may have been made, which may have resulted in a morefavourable outcome.The man was taking a number of medications known to cause or exacerbateconstipation (e.g. iron, Olanzapine Tartrate, and Lamotrigine). Iron was beingtaken, yet there was no obvious evidence of the presence of iron deficiencyanemia. Even if he had been iron deficient at some point in the past, it is expectedhe surely was replete long before the 14 months he received the iron in the LTCH.According to the Compendium of Pharmaceuticals and Specialties (CPS), 10% ofpatients taking iron can develop constipation.In addition, the man was taking a large dose of Olanzapine Tartrate during hisentire stay in the LTCH. Lamotrigine may interact with, and potentiate the sedatingeffects of Olanzapine Tartrate. According to the CPS, 9% of patients takingOlanzapine Tartrate can become constipated.The man’s behavioural problems appeared to be situational (e.g. when care wasbeing provided). Anti-psychotic medications may not have been the best choice forthe management of a situationally induced abnormal behaviour. Considerationcould have been given to tapering or stopping the dosage of Olanzapine Tartrate.The frequency of the man’s falls increased dramatically over the last few months ofhis life. Of concern was the absence of a thorough medical assessment to look fora reason for the falls. The increased number of falls may have been related to hisconstipation, his medications, or some combination thereof.The man was on a relatively low dose of Lactulose. It is uncertain if increasing thedosage of Lactulose, rather than relying on enemas and suppositories, might havebeen a more effective treatment.Recommendations1. Health care professionals should be reminded that constipation and obstipation are common, preventable, and treatable medical conditions that affect the elderly. Untreated, these conditions can be devastating and may even result in death. Once obstipation is suspected, aggressive investigation and treatment should be considered on a case by case basis.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 36
    • As with many geriatric syndromes, obstipation may present either typically (e.g. abdominal pain, fecal incontinence) or atypically (e.g. confusion, delirium). Health care professionals should be especially wary of elderly patients who present with constipation/obstipation who have associated systemic symptoms (e.g. tachycardia). In these cases, the ordering of laboratory investigations and an EKG should be considered on a case by case basis. The occurrence of overflow incontinence should alert the treating health care professionals to the possibility that the patient has developed fecal impaction with overflow incontinence. Fecal impaction can be difficult to treat and should be treated vigorously when present. Careful abdominal and rectal examinations should be performed. The finding of soft stool, or no stool in the rectum, does not absolutely rule out the presence of fecal impaction. In these cases, an abdominal flat plate X-ray and/or CT scan should be ordered to rule out the possibility of a higher impaction that cannot be detected on rectal examination and/or a developing acute/subacute bowel obstruction (i.e. dilated loops of bowel with air/fluid levels). While manual disimpaction should be the first intervention attempted, the presence of obstipation with a higher impaction should primarily be managed with enemas to clear the bowel from below. In some cases, the addition of oral osmotic laxatives such as Lactulose, can be used to clear the bowel from above. Gastrointestinal lavage solutions have also been proven to be very effective in treating fecal impaction. Health care professionals should always be observant for the development of complications and especially for the development of complications related to the treatment of obstipation/fecal impaction. References: Goldlist, B., Gordon, M., Naglie, G. (1992). Constipation can be deadly. Canadian Family Physician. 38, 2419-2421. Mayo Clinic Proceedings. Evaluation and treatment of constipation and fecal impaction in adults. (Review) (12 refs) 73(9):881-6 quiz i887, Sept. 1998. Ortiz-Cmacho, C.M. Mayo Clinic Prather. Institution Gastroenterology Research Unit, Minnesota, U.S.A.2. Health care professionals should be reminded that when constipation or other medical issues occur in the elderly and are thought to be due to, or exacerbated by, medications, the recommended initial approach should be to discontinue or replace the suspected medication rather than adding additional medications. Reference: Rochon, P. & Gurwitz, J. (1997). Optimizing drug treatment for elderly people: the prescribing cascade. British Medical Journal, 315, 1096-1099.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 37
    • 3. Health care professionals should be reminded of the importance of adjusting the dosages of medications to obtain an effective, therapeutic outcome (e.g. don’t treat by dose, treat by outcome).4. Health care professionals should be reminded that falls in the elderly, and especially repeated falls, can have potentially serious outcomes. All long term care institutions in the Province of Ontario should develop a comprehensive and evidence based falls prevention program which should include, but not be limited to, assessment strategies including a review of the elderly patient’s medication profile, therapeutic intervention and management plans, and prevention strategies. When elderly residents fall, long term care facility staff should communicate this information to the resident’s physician in a timely fashion for the purpose of allowing the physician to assess the resident for the presence of any injury and look for possible precipitating causes for the fall.5. Health care professionals should be reminded that disease presentation in the elderly is frequently atypical and may vary greatly from patient to patient. A subtle change in patient’s clinical status may well indicate that something serious is going on which may not be readily apparent. The underlying cause(s) of these atypical presentations may be missed if the investigator does not obtain an appropriate history, conduct a thorough examination, and judiciously utilize available laboratory and imaging resources. An increase in the number of falls for example, may be due to the development of increasing constipation which, if left untreated, may result in serious morbidity and or mortality.Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 38
    • Analysis of Recommendations: 2004 - 2009 2004 2005 2006 2007 2008 2009Total Number of Cases 25 28 27 17 18 20ReviewedTotal Number of 67 59 71 35 46 39Recommendations# of Cases and Recommendations Based on Area of Concern (Note: Cases may havemore than one area of concern identified)Medical / Nursing Management Number of cases with area ofconcern: 14 12 10 8 7 7% of total cases: 56% 43% 37% 47% 39% 35%Number of recommendations: 22 22 30 17 12 15% of total recommendations: 33% 37% 42% 48% 26% 39%Communication / DocumentationNumber of cases with area ofconcern: 9 7 6 4 6 3% of total cases: 36% 25% 22% 24% 33% 15%Number of recommendations: 13 9 8 6 7 6% of total recommendations: 19% 15% 11% 17% 15% 15%Use of Drugs in the ElderlyNumber of cases with area ofconcern: 7 5 8 3 5 4% of total cases: 28% 18% 30% 18% 28% 20%Number of recommendations: 9 8 14 3 6 6% of total recommendations: 13% 14% 20% 9% 13% 15%Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 39
    • Admission, Discharge and TransferProceduresNumber of cases with area of 3 3 3 1 1 0concern: 12% 11% 11% 6% 6%% of total cases: 3 4 4 2 2Number of recommendations: 4% 7% 6% 6% 4%% of total recommendations:Determination of Capacity andConsent for Treatment / DNRNumber of cases with area of 2 2 0 0 0 0concern: 8% 7%% of total cases: 1 3Number of recommendations: 2% 5%% of total recommendations:Use of RestraintsNumber of cases with area of 0 0 1 01 0 0concern: n/a 4%% of total cases: n/a 0 4Number of recommendations: 0 n/a 6% 6%% of total recommendations: n/aAcute and Long Term Care Industry,including the Ministry of Health andLong-Term CareNumber of cases with area ofconcern: 12 72 9 4 10 6% of total cases: 48% 25% 335% 24% 56% 30%Number of recommendations: 14 10 10 7 17 12% of total recommendations: 21% 17% 14% 20% 37% 31%Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 40
    • AcknowledgementsThe Geriatric and Long Term Care Review Committee would like to acknowledgethe efforts of Mrs. Cathy Traynor for her dedicated and invaluable service in thepreparation of the individual reports and the Twentieth Annual Report.Questions and comments regarding this report may be directed to:Ms. Kathy KerrExecutive Lead – Committee ManagementOffice of the Chief Coroner26 Grenville StreetToronto, OntarioM7A 2G9Kathy.M.Kerr@Ontario.caGeriatric and Long Term Care Review Committee – 20th Annual Report – 2009 41