ONTARIO NURSES ASSOCIATION. Submission to Consultations to Address Abuse and Neglect in Long-Term Care Homes

Transcription

1 ONTARIO NURSES ASSOCIATION Submission to Consultations to Address Abuse and Neglect in Long-Term Care Homes Long-Term Care Task Force on Resident Care and Safety March 15, 2012 ONTARIO NURSES ASSOCIATION 85 Grenville Street, Suite 400 Toronto, ON M5S 3A2 Phone: (416) Fax: (416) Web site:

2 INTRODUCTION The Ontario Nurses Association (ONA) is the union representing 58,000 front-line registered nurses and allied health professionals and more than 13,000 nursing student affiliates providing care in Ontario hospitals, long-term care facilities, public health, the community and industry. We welcome the opportunity to provide our views to the Long-Term Care Task Force on Resident Care and Safety. ONA represents registered nurses (RNs), registered practical nurses (RPNs) and personal support workers (PSWs) in the long-term care sector. Addressing abuse and neglect in long-term care homes is a fundamental concern for nurses and other staff who deliver care to residents living in long-term care homes each and every day. Not only are longterm care facilities homes for residents, they are workplaces for nurses who face immense obstacles to provide the quality care that residents deserve and absolutely must be able to expect. Vulnerable and frail seniors living in long-term care homes must be able to live in dignity and to feel protected in their homes. You have asked that those interested in providing input to the Task Force respond to specific questions to be addressed. Our submission is structured to follow your requested format. 1. Based on what you have seen, heard or experienced, please tell us the key things that make a long-term care home a place where residents feel safe, respected and well cared for. From ONA s perspective, based on the experiences of our members working in long-term care homes, a number of systemic issues provide the framework for taking action in the long-term care sector. It is our view that three main and interlinked systemic issues must be reconsidered: skill mix in terms of the staffing model providing care to residents, the overall staffing levels, and the growing acuity level and level of cognitively impaired residents who reside in long-term care homes. With these systemic issues in mind, ONA believes four key elements are essential to safer long-term care home environments where residents receive the care to meet their needs: evidence-based staffing standards, levels of resident care, and specialized training; a culture of openness not fear, including a culture of safety and a quality work environment for long-term care staff; enhanced transparency and accountability regarding public funding for long-term care; and enhanced reporting of inspection, compliance and staffing in long-term care homes. ONA Submission to LTC Task Force Consultations/March 15,

3 Evidence-Based Staffing Standards and Levels of Resident Care Abuse and neglect in Ontario long-term care homes is not a new or recent phenomenon. It has a long history that is clearly linked to the lack of mandatory standards for nursing and personal care staffing levels. The 2004 Annual Report of the Office of the Provincial Auditor of Ontario clearly sets out the role of, and relationship between, the Ministry of Health and Long-Term Care and long-term care homes: Long-term-care facilities provide care and services to individuals who are unable to live independently at home and require the availability of round-the-clock nursing service to meet their daily nursing and personal care needs.the Ministry s key responsibility regarding the operations of long-term-care facilities is to ensure that they are delivering services to residents in accordance with their service agreements with the Ministry and in compliance with applicable legislation and ministry policies. 1 Minimum staffing standards for nursing and personal care and levels of resident care are fundamental to ensure that resident daily nursing and personal care needs are met. In the current regulatory regime for long-term care homes, there is no assurance that residents will receive the level of nursing and personal care they need. There is no fundamental principle clearly setting out that residents have the right to access the nursing and personal care that they need. There is no ongoing evidence-based staffing standard for nursing and personal care. There is not even a statutory requirement that long-term care homes have sufficient nursing and personal care staff to meet its statutory obligations to residents. There is no provision for the adoption of quantifiable staffing standards for nursing and personal care or levels of such care to ensure resident needs are met. This omission continues to be perplexing because the government and long-term care home operators are well aware of recommendations from the 2005 coroner s inquest at Casa Verde. Three key recommendations in that inquest related to establishing minimum staffing standards for nursing and personal care and levels of resident care. Recommendation 28 was that the MOHLTC retain Price Waterhouse Coopers, or a similar consultant, to update the January 2001 Report of a Study to Review Levels of Service and Responses to Need in a Sample of Ontario LTC Facilities and Selected Comparators, and to have an evidence based study of the present situation determine the appropriate staffing levels for Ontario LTC facilities given the significant number of Ontario residents with cognitive impairment and complex care in LTC facilities. 2 ONA Submission to LTC Task Force Consultations/March 15,

4 Recommendation 30 was that the MOHLTC should set out standards based on this information to ensure residents are given appropriate nursing and other staff hours. 3 The new Long-Term Care Homes Act sets out some staffing standards for certain classifications but not for nursing and personal care. Further, Recommendation 29 in the Case Verde coroner s inquest proposed that the MOHLTC in the interim, pending the evidence-based study should fund and set standards requiring LTC facilities to increase staffing levels to, on average, no less than.59 RN hours per resident per day and 3.06 per resident per day overall nursing and personal care for the average Ontario case mix measure. The funding formula for the Nursing and Personal Care envelope must be immediately adjusted to reflect this minimum staffing. In addition, the 2004 provincial auditor s report made two staffing recommendations to the Ministry to ensure that long-term care homes provide the level of care required by residents and that the assessed needs of residents are being met: track staff-to-resident ratios, the number of registered-nursing hours per resident, and the mix of registered to non-registered nursing staff and determine whether the levels of care provided are meeting the assessed needs of residents; and develop appropriate staffing standards for long-term-care facilities. 4 Clearly, the provincial auditor was concerned that, in order to meet residents' assessed needs, the Ministry had to determine whether the needs are being met and adopt "appropriate staffing standards." The Ministry also provided the provincial auditor the following response on the status of efforts at that time to implement the auditor s recommendations: determining staff deployment using a tool that captures numbers of all registered and non-registered staff in all resident floors and/or care areas; assessing in depth the care needed by and provided to residents using a standardized provincial assessment tool that gathers the relevant information; ONA Submission to LTC Task Force Consultations/March 15,

5 observing resident grooming, positioning, call-bell access, and so on, by walking through all resident areas; and reviewing call-bell response times. 5 We agree with the Ministry s statement that they now more accurately identify how much staffing the home operator provides (first bullet), although that staffing is not publicly reported in any accessible manner. The Ministry claims they assess how much care is provided to residents (second bullet), but we disagree, because the tool they use only captures care need, not care actually provided. Thus, in our opinion, the Ministry has still not complied with the first bullet of the auditor's recommendations; only the first half of the second bullet and now appears to be moving in the direction of the third bullet through enhanced inspection processes. The provincial auditor recommended that there be staffing standards for nursing and personal care and that staffing should not be limited to ad hoc decisions of long-term care homes operators based upon funding actually received. Furthermore, the provincial auditor clearly intends that the staffing standards for nursing and personal care be sufficient to meet resident care need. Yet action on these recommendations has not been implemented. The current requirement (and exceptions in regulation) in section 8(3) of the Long-Term Care Homes Act to have at least one RN on duty and present in the home at all times does not guarantee residents will have a greater amount of RN care. It does not guarantee that each resident will be assessed by an RN. It does not guarantee that each resident will get even the smallest amount of RN care. The only way to guarantee resident hours of care is to set and to fund minimum standards for hours of nursing and personal care, including minimum standards for the quantity of RN care. A number of research studies have also examined the relationship between registered nurse staffing levels and the quality of care in nursing homes. For example, higher RN staffing levels (.5 to.67 RN hours per resident per day) were found to be associated with lower pressure ulcer rates, urinary tract infections and hospitalizations. 6 ONA Submission to LTC Task Force Consultations/March 15,

6 In another study, residents receiving 30 to 40 minutes of RN direct care per day were 84 per cent less likely to develop a pressure ulcer and 42 per cent less likely to experience deterioration in their ability to perform activities of daily living. 7 A further study identified staffing level thresholds for RNs above which no quality improvements were observed at between.55 and.75 RN hours per resident per day. 8 Improved RN staffing levels clearly contribute to the avoidance of adverse care outcomes and additional RN staffing improves quality care for residents. 9 Our recommendation is to implement 3.5 hours of nursing and personal care, including.68 hours of RN care for the average Ontario case mix measure. This staffing standard could be revised based on the implementation of an evidence-based study as recommended by the coroner s inquest. Growing Resident Needs for Specialized Care In addition to a renewed commitment to improving staff skill mix and staffing levels to deliver the care residents need, we believe that solutions to address the growing care needs and acuity level of residents recommended by previous coroner s inquests remain unaddressed and have not been implemented. In particular, the Casa Verde inquest, in recommendation 22, recommended that: the MOHLTC should fund specialized facilities to care for demented or cognitively impaired residents exhibiting aggressive behaviour as an alternative to LTC facilities. Funding for these facilities should be based on a formula that accounts for the complex high-care needs of these residents in order that the facility be staffed by regulated Health Care Professionals (RN s and RPN s) who are trained in PIECES, and in sufficient numbers to care for these complex and behaviourally difficult residents. It is clear that there is a broader need for specialized facilities and units as recommended by the Casa Verde inquest. In addition, events that have transpired since the Case Verde inquest show that the specialized staff training recommended has not been systematically implemented. The Case Verde inquest made a number of recommendations related to specialized staff training related to the unpredictability and risk associated with cognitively impaired residents showing aggressive and inappropriate behaviour: Recommendation 33: Pending the remodeling of the future system and implementation of training for all staff, additional funding must be provided and tracked to ensure that a PIECES trained Registered Nurse at each facility is designated for those residents on each shift, due to the unpredictability of behaviours and level of risk associated with these residents. ONA Submission to LTC Task Force Consultations/March 15,

7 Recommendation 40: The MOHLTC should set mandatory standards and provide designated funding to ensure that all staff interacting with cognitively impaired residents in LTC are PIECES/U-First trained. This includes those individuals who make decisions regarding admission and placement, as well as those managing the individual s care. To our knowledge, no systematic analysis and evaluation of the implementation of these and other recommendations or the tracking of funding for specialized staff training has been undertaken. Our recommendation is to immediately conduct a provincial assessment into specialized staff training in long-term care homes to assess where the need is greatest for additional training to comply with the coroner s recommendations. A safer long-term care home environment requires skill mix changes, an improved overall staffing standard and specialized training for staff caring for residents. 2. From your experience and knowledge, what kinds of things lead to abuse and neglect in long-term care homes? (Abuse includes emotional, financial, sexual, verbal as well as physical abuse.) As we have highlighted in the previous section, and based on very clear findings in the literature, a higher RN mix is positively related to quality resident care, as is an overall higher mandatory staffing standard for nursing and personal care. In addition, there exist elements of residents refusing care resulting from cognitive and other resident challenges. A combination of factors is often at play: staffing ratios, resident acuity levels and associated behaviours, and constraints due to building design that is not conducive to quality resident care. For example, the physical layout of the long-term care home is relevant as the greater the distance between residents rooms and any nursing station or other location where the RN works, will increase the time it takes to arrive at the resident s room and therefore reduce the number of residents who can be assessed and/or assisted during a single shift. As well, as discussed above, the coroner s jury that reviewed the deaths at Casa Verde made several very important recommendations that have not been implemented and should be implemented to increase safety in long-term care homes related to specialized PIECES and related training, including individuals who make decisions regarding admission, placement and post-placement suitability. ONA Submission to LTC Task Force Consultations/March 15,

8 Improper assessment of cognitively impaired individuals before placement creates potential issues, challenges and risk in the provision of daily care. A full assessment of the applicant s mental health status and behavioral problems prior to the determination of eligibility is essential, as well as an assessment of the existing resident population in the long-term care home (such as, the frailty of other residents, the competing high needs of other residents, the level of nursing and personal care staffing, the numbers of Registered Nurses available, the presence of an appropriate specialty unit). In some cases, after admission, a resident may be found to have a complexity of care such as aggressive behaviours that cannot be safely managed, or to have requirements beyond the staffing ratios and staff expertise of a specific long-term care home, and the solution may require placement in an alternative, more appropriate setting. The RAI-HC documentation, medical documentation and family information can and are altered to have a person placed urgently and out of an unsuitable home environment, and this has not changed. ONA continues to hear about cases of documentation changing to ensure people are placed regardless of whether or not the home can accommodate the resident s needs. 3. In your view, how can incidents of emotional, financial, sexual, verbal and physical abuse and neglect be prevented? Tracking and Public Reporting: Staffing and Training It is our view that the staffing issues we have discussed are systemic and must be addressed on a system level. This would include tracking nursing and personal care staffing and tracking specialized training for nursing and personal care staff on a provincial and an individual home basis. This would require public reporting of nursing and personal care staffing both provincially and for each long-term care home, including specialized training for nursing and personal care staff. This should be done in the home reports on the Ministry of Health and Long-Term Care website. We also believe that the new Long-Term Care Quality Inspection Program should assist. However, it is noted that the current level of detail in the publicly reported home inspection reports provide a very high-level summary and do not provide guidance on actions that are being taken to prevent the incident that resulted in the complaint and that triggered the inspection. In this sense, the public reports do not necessarily provide assurance and transparency that the issues have been addressed. ONA Submission to LTC Task Force Consultations/March 15,

9 Cultural Transformation The larger issue to address is the development of a culture of openness and safety in every long-term care home. In our view, such a culture must be developed to replace the current culture of fear and complaint-based system that remains in which staff are reluctant to speak out in fear of retribution. We will talk further about stronger whistleblower protection below, but here we want to highlight the cultural transformation that must take place from the top levels of longterm care organizations to the leadership in each long-term care home. 10 However, this retribution may also occur from co-workers versus home management and this can be more damaging if the reporting staff are not supported by management. 4. By law, a long-term care home must post the government s Long-Term Care ACTION LINE phone number for anyone to call if they want to report the abuse or neglect of a resident or even the suspicion of abuse or neglect. When a call is made, a government inspector must investigate and the report of the investigation must be clearly posted in the home. 4a. When a resident is abused or neglected, why do you think it might not be reported? 4b. Why do you think the outcome might not be communicated properly, as required by law? Further to our discussion of the current culture of fear and reprisal that pervades the long-term care sector, we believe that stronger protection from reprisal is necessary to begin the cultural transformation that is required and to empower staff. Currently, the number of RNs in any home is greatly outnumbered by the number of RPN and PSWs. ONA RNs report that they experience reprisals from the RPNs and PSWs if the RN reports or directs to provide care in another way or reports abuse. These RNs are often accused of harassing the other staff leading to a culture of fear for the RNs in these facilities. These RNs are usually the only RN in the home and there are no supportive witnesses for their actions. These RNs are often bullied into silence by their co-workers and a lack of supportive management teams. Stronger Whistleblower Protection The Long-Term Care Home Act fails to provide any preventive or deterrence measures against retaliation. There is a general reluctance of employees to report abuse because of the fear of retaliation. Without provisions requiring long-term care home operators to prove misconduct of employees on other grounds before imposing discipline, employees will fear trumped up charges will be laid against them by the employer and will have major hesitations against ONA Submission to LTC Task Force Consultations/March 15,

10 reporting abuse. The current provision denies the employee a remedy until the end of a labour board proceeding, or disputes resolution mechanism under collective agreements, which may take a long time and cost a lot in monetary and emotional resources. Even if the whistleblower does not give up and is eventually reinstated, in the interim, the message has been strongly conveyed to other potential whistleblowers as to the reaction they will encounter if they act on their statutory obligation to report abuse. We strongly urge you to study and make recommendations for the elements of whistleblower protection that need to be in place to encourage greater compliance with the duty to report abuse. In addition, broader public education on the new inspection and compliance processes for longterm care homes needs to be undertaken to empower family and friends of residents to take action to make complaints and to report. CONCLUSION We sincerely request that our recommendations be given serious consideration so that residents in long-term care homes receive the appropriate level of care they deserve to live safely and with dignity. 1 See 2004 Annual Report of the Office of the Provincial Auditor of Ontario, Section 4.04, Long-Term Care Facilities Activity (follow-up to VFM Section 3.04, 2002 Annual Report), p. 381, accessed at 2 See Coroner s Inquest, Casa Verde Nursing Home, Jury Verdict and Recommendations, April Ibid. 4 See 2004 Annual Report of the Office of the Provincial Auditor of Ontario, Section 4.04, Long-Term Care Facilities Activity (follow-up to VFM Section 3.04, 2002 Annual Report), p. 385, accessed at The Auditor s 3 rd bullet we reference on p. 9 can be found at p. 19 in our submission. 5 Ibid., p See Dorr D.A. et al. Cost Analysis of Nursing Home Registered Nurse Staffing Times. Journal of American Geriatrics Society 2005, 53: See Horn S.D., et al. RN Staffing Time and Outcomes of Long-Stay Nursing Home Residents: Pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care. American Journal of Nursing. 2005, 105: See Abt Associates Inc. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Report to Congress: Phase II Final Volume I, p For the most recent research on the benefits to residents of higher registered nurse staffing levels, see Harrington, Charlene et al. Nursing Home Staffing Standards and Staffing Levels in Six Countries, Journal of Nursing Scholarship 2012, 44(1): Nurse Staffing and Deficiencies in the Largest For- Profit Nursing Home Chains and Chains Owned by Private Equity Companies, Health Services Research (1): See, for example, Annalee Yassi and Tina Hancock, Patient Safety Worker Safety: Building a Culture of Safety to Improve Healthcare Worker and Patient Well-Being, Health Care Quarterly October 2005 Vol. 8 Special Issue. ONA Submission to LTC Task Force Consultations/March 15,