1. Twentieth Annual Report
Of the
Geriatric and Long Term Care
Review Committee
Office of the Chief Coroner
Province of Ontario
September 2010

2. Table of Contents
Introduction ...........................................................................................................1
Methodology and Case Review Process ..............................................................2
Recommendations Process ..................................................................................2
Geriatric and Long Term Care Review: Committee Activities - 2009 ....................3
2009 Case Review Summary ...............................................................................4
Recommendations 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 ........................................................................10
Summary of Recommendations from Cases Reviewed - 2009...........................13
Figure 1 – Percentage of Recommendations Based on Area of Concern - 200914
Case Reviews .....................................................................................................15
Case 1 .............................................................................................................15
Case 2 .............................................................................................................17
Case 3 .............................................................................................................22
Case 4 .............................................................................................................29
Case 5 .............................................................................................................34
Analysis of Recommendations: 2004 - 2009.......................................................39
Acknowledgements.............................................................................................41

3. Introduction
Originally formed in December 1989, the Geriatric and Long Term Care Review
Committee to the Chief Coroner for the Province of Ontario has just completed its
twentieth full year of operation.
The Committee membership in 2009 included:
Dr. Peter Clark Regional Supervising Coroner,
Committee Chair
Ms. Kathy Kerr Executive Lead
Dr. Barbara Clive Geriatrician
Ms. Sheila Driscoll Ministry of Health and Long
Term Care
Dr. Sid Feldman Family Physician
Dr. Margaret Found Family Physician/Coroner
Dr. Lynne Fulton Emergency Room Physician
Dr. Heather Gilley Geriatrician
Dr. Barry Goldlist Geriatrician
Dr. Michael Gordon Geriatrician
Dr. Jennifer Ingram Geriatrician
Ms. Margaret Leaver-Power Nutritionist
Ms. Karen Thompson Registered Dietician
When necessary, health care professionals from other disciplines, including
psychogeriatrics, gastroenterology and infectious diseases, have assisted the
Committee with case reviews.
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 1

4. Methodology and Case Review Process
Geriatric and long term care cases are referred to the Committee through the
Regional Supervising Coroners in the province.
The Geriatric and Long Term Care Review Committee conducts an independent
review of the available records relevant to the specific case and prepares a final
report which may include recommendations aimed towards the prevention of future
deaths in similar circumstances.
Recommendations Process
The recommendations suggested by the Geriatric and Long Term Care Review
Committee are intended to promote discussion and initiate change. The
recommendations are not to be interpreted as policy directives from any agency or
ministry of government, including the Office of the Chief Coroner. The
recommendations focus on preventing future similar deaths by building awareness
and recognition of issues affecting the geriatric and long term care communities
within Ontario.
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 2

5. Geriatric and Long Term Care Review: Committee Activities - 2009
In 2009, the Geriatric and Long Term Care Review Committee (GLTCRC) reviewed
a total of 20 cases which resulted in 39 recommendations. There were 8 cases
reviewed 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 associations
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 3

6. 2009 Case Review Summary
In 2009, the Geriatric and Long Term Care Review Committee reviewed a total of
20 coroners’ cases that were referred to them involving residents of long term care
facilities and the elderly. Upon reviewing the cases, the committee generated a
total of 39 recommendations aimed at preventing future similar deaths. These
recommendations 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 Care
Recommendations were distributed to relevant individuals, facilities, ministries,
agencies, special interest groups, health care professionals (and their licensing
bodies) and coroners, through the relevant Regional Supervising Coroners.
Recommendations were also shared with Chief Coroners and Medical Examiners in
other Canadian jurisdictions and to any other individuals or groups upon request.
The Geriatric and Long Term Care Review Committee acknowledges that quality
long term care does exist in Ontario. The deaths reviewed represent only a small
portion of the total number of cases investigated by coroners that involve residents
of long term care facilities and the elderly.
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 4

7. Recommendations from 2009 cases
The following recommendations were made after a thorough review of the 20 cases
referred to the Geriatric and Long Term Care Review Committee in 2009. These
recommendations are not to be interpreted as policy directives. Recommendations
are intended to promote discussion and initiate change. Recommendations focus
on 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

8. 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

9. 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. 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

11. 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

12. 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 of
Health 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

13. 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 regarding
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 11

14. 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

15. Summary of Recommendations from Cases Reviewed - 2009
Major 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 12
Industry, 30% 31%
Including the Ministry of Health and
Long-Term Care
Total number of cases reviewed 20
Total number of recommendations made 39
Total number of cases with no 8
recommendations
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 13

16. 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

17. Case Reviews
To help demonstrate the complexity of issues examined by the Geriatric and Long
Term Care Review Committee, 6 of the 20 cases reviewed in 2009 are summarized
below. The selected cases demonstrate the comprehensive and thorough review
and recommendation process undertaken by the Committee, as well as highlight
some of the general themes of concern that are consistent throughout the cases
reviewed.
Case 1
Reference: 2008-6984
Issue:
Management of an elderly person in the community setting, following discharge
from a long term care setting.
Summary:
This is the case of a 57 year old intellectually disabled woman who died in July
2008 after being left unsupervised in a bathtub for approximately 10 minutes. A
post mortem was conducted and there was no definitive anatomic or toxicological
cause of death although the circumstances are consistent with death due to
drowning.
The woman had resided in an regional centre for individuals with developmental
disabilities 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 was
consistent with a five-year plan that had been announced by the provincial
government in 2004, to close three regional centres for individuals with
developmental disabilities. The mandate of the initiative was to meet the goals of
the “Challenges and Opportunities” paper that was written in 1987. The paper
directed that all facility settings for people with development disabilities in the
Province of Ontario would be closed and community based supports would be
provided.
A detailed “Transition Plan” for the woman was started well in advance of her
transfer to the community. In June 2005, there were discussions with her family
regarding the subsequent closure and move and although the family were not
pleased with the closure of the facility, they requested that the woman be placed in
a community in close proximity to their residence.
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 15

18. In June 2006, a detailed plan outlining the woman’s care needs was developed with
input from her family and staff from the centre. The plan identified her “likes and
dislikes”, as well as “positive rituals or routines requiring assistance.” The plan
noted that the woman did not have any knowledge around safety and that she
needed constant supervision. With respect to bathing, it was identified that the
woman required “hands on support.”
In August 2006, a Resident Assessment Instrument (RAI) was done and the
woman was identified as being intellectually disabled. Her cognition was described
as “severely disabled” and she was identified as requiring “extensive assistance”
when bathing.
In October 2006, a detailed facilities individual support plan was developed for the
woman. The plan included a timetable which identified a daily morning bath.
There appeared to be significant planning for the woman’s transition from the centr
to the community living residence. The move was viewed as positive by both her
family and the psychiatrist who had cared for her for many years. Transition
documentation identified the woman’s lack of insight into safety requirements and
the need for supervision.
The woman had been investigated for excessive daytime drowsiness. The
diagnosis of sleep apnea and narcolepsy could not be made. It was noted that she
was somewhat drowsy and could easily drop off to sleep even while engaged in a
conversation. Throughout 2006, the woman was investigated by numerous
specialists because of her syncopal episodes. The consultant neurologist noted
that the “drop attacks” may have been present for four years. The episodes were
occurring daily while she was standing, sitting, or lying down. She had very brief
episodes of unresponsiveness and recovered spontaneously. She was drowsy
much of the time. On only one occasion was she observed to have convulsive
movements. Her last documented seizure was in 2002.
In July 2008, while in the community living residence, the woman was left
unsupervised 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 the
decision that she could be left unsupervised in the bath. Previously, in the centre,
she had received constant supervision during her bath. The discharge/transfer
recommendation specifically referenced the need for constant supervision while
bathing. It could not be determined from the review if the bathing supervision issue
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 16

19. was discussed with the woman’s substitute decision maker. Decisions regarding
the quality of life and safety risks should always be discussed with the substitute
decision maker.
Based on the documentation submitted for review, it is unclear whether alternative
safety training or increased qualifications of the community residence staff would
have 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 2
Reference 2008-735
Issue:
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 two
miles 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 her
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 17

20. admission. Her other past medical diagnoses included osteoporosis, hypertension
and mild, chronic anemia.
On February 29, 2008, the woman presented to the emergency room (ER) of the
GH with mild ataxia, generalized weakness, and episodes of confusion.
Medications being taken at this time included: Hydrochlorothiazide, Irbesartan,
Alendronate Sodium, Rosuvastatin, Calcium, Fosavance, Prednisone, and
Ranitidine Hydrochloride.
The ER note commented on the presence of increasing confusion, disorientation,
memory loss and decreased ability to perform activities of daily living (ADLs). On
examination, there was mild global weakness in the absence of focal neurological
findings and the woman required assistance to walk. Initial laboratory
investigations revealed a hemoglobin of 105 and a sodium of 124. The
hyponatremia rapidly resolved with the stopping of Hydrochlorothiazide. Her gait
improved, however the confusion continued. A CT scan of the brain revealed
atrophy, small vessel ischemic disease and probable basal ganglia lacunar infarcts.
An occupational therapy (OT) assessment revealed that the woman exhibited poor
attention when performing tasks, including her ADLs. She was completely unsafe
with meal preparation. Her Mimi Mental Status Examination (MMSE) score was
16/30. During hospitalization, her cognitive function did not improve so the initial
plan 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. Her
mobility rapidly returned to her baseline, so no physiotherapy was required. The
Occupational Therapist continued to monitor the woman’s progress.
Both before and after transfer to the Alternative Level of Care (ALC) ward, the
woman had recurrent episodes of chest pain which contributed to the development
of anxiety. Lorazepam was infrequently administered to control the anxiety. Her
daughter advised that the episodes of chest pain were long standing and that
previous investigations had been negative. Numerous electrocardiograms and
troponins were reported to be negative. Glyceryl Trinitrate Spray and
gastrointestinal medications were given resulting in a variable response to the chest
pain. A firm diagnosis was never established.
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 18

21. The daughter expressed concern about her mother’s poor intake in April 2008. The
woman’s indices of dehydration (i.e. creatinine and blood urea nitrogen), were
monitored and did not increase until the terminal events occurred.
On April 14, 2008, the woman was assessed by the nurse practitioner. Laboratory
investigations revealed a white blood count (WBC) of 17.9 with a neutrophil count
of 15.6. A urine culture was ordered.
On April 15, 2008, the woman complained of headaches. It was noted that her
intermittent confusion continued.
On April 16, 2008, her WBC had dropped to 12.3, which was within her usual
range.
On April 18, 2008, the hospitalist noted that the woman was afebrile and had no
dysuria. Antibiotics were not ordered as the urine culture was reported to be only
growing mixed culture. A repeat urine culture was ordered. On April 21, 2008, the
hospitalist noted no new findings.
On April 23, 2008, the woman complained of a sore throat. Examination of her
chest was negative. A throat swab was taken and was eventually reported to be
negative. Her urine culture was reported to be positive and Ciprofloxacin was
prescribed.
On April 25, 2008, plans were made to discharge the woman to her daughter’s
home with Community Care Access Centre (CCAC) support and a backup plan for
admission to a LTCH, if necessary. At 1745 hours, the woman had an episode of
chest pain which was relieved with Glyceryl Trinitrate Spray. At 1810 hours, the
woman fell. Nursing staff were alerted by another resident and responded. The
woman was found on the floor outside the bathroom. On examination, she had a
skin abrasion on the left side of her head above the eye. The wound was cleansed
and the woman’s physician and daughter were notified. Nursing staff documented
that 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 that
was aggravated by breathing and on palpation. Nursing staff noted that she was
restless and uncomfortable. Acetaminophen was given for pain control and
Lorazepam for the associated anxiety. Investigations ordered included a CT scan
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 19

22. of her head and insertion of a Foley catheter with the taking of a urine culture. She
continued to complain that the pain was not relieved by the Acetaminophen.
On April 27, 2008, nursing staff noted the presence of extensive bruising over her
chest 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 catheter
was stretched. A lap belt restraint was applied. Later that day, the CT scan of her
head was reported to show no new changes and the urine culture was reported to
be negative. On examination, crackles were now noted to be present in the right
lung base. Acetaminophen continued to be given for pain. Overnight, she
continued to complain of pain which was not relieved by Acetaminophen. Although
the woman was in agony, the nursing plan was to wait until the morning to request
a more effective analgesic.
At 0935 hours on April 29, 2008, the woman had a chest X-ray that revealed the
presence of fractured ribs. Her WBC, urea and creatinine were reported to be in
the normal range. Morphine Sulfate was prescribed to control the pain.
On April 30, 2008, nursing staff noted that the Morphine Sulfate was effective in
controlling the woman’s pain and her daughter consented to the application of
restraints to prevent unsupervised wandering. Over the next two days, nursing staff
reported that the woman’s pain was not always relieved by the Morphine Sulfate
and 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 creatinine
was increased to 133. The daughter called later that day to express concerns
regarding her mother’s care, particularly with the lack of oral fluid intake. She
stated that she could not take her mother home in this condition and requested a
conference. 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 bathroom
with her pants halfway down and stool on her buttocks. Her glasses were broken
and she was bleeding from a head wound. Nursing staff put her on a stretcher to
take her down to the ER. Apparently, an ER staff person told the ALC nursing staff
not to bring her down to the ER but rather to call the hospitalist. The hospitalist was
contacted, but did not initially respond. Eventually, the hospitalist responded on
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 20

23. May 4, 2008, at which time Hydromorphone and Quetiapine Fumarate were
ordered. Nursing staff noted that the woman’s blood pressure remained low and
she required Oxygen to maintain her saturation. The woman’s daughter had a
difficult time getting in contact and communicating with the hospitalist.
At 2230 hours, the on-call physician called the daughter as the woman’s clinical
status continued to deteriorate. She was too drowsy to eat her dinner and her
WBC 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 and
intravenous fluids and antibiotics would be administered. Attempts were made to
arrange a transfer to an acute care bed in the hospital, but there were no beds
available.
The woman’s clinical condition continued to deteriorate overnight. She
subsequently 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 care
provided to the woman following her fall. In particular, concerns were identified with
the pain management procedure utilized, the lack of communication between
healthcare providers and the family, the use of restraints and the use of urinary
catheters.
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

24. 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 3
Reference 2007-673
Issue:
Placement and management of the elderly with abnormal behaviours in the long
term care setting.
History:
The deceased was a 59 year old male resident of a Ministry of Health and Long
Term Care (MOHLTC) licensed Long Term Care Home (LTCH).
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 22

25. 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, controlled
on anti-convulsant medications) and hearing loss (requiring amplification of
television/radio).
The deceased lived with Community Living for most of his adult life. He moved into
an independent apartment by himself approximately 7 years prior to his death and
was supported by services provided through the local Community Service Centre.
These services included daily supervision and assistance with meals, dressing and
bathing, homemaking assistance and a Social Worker who would assist him with
instrumental activities of daily living (ADL), like shopping and banking.
Since the death of his mother in 2001, the deceased began to have more difficulty
caring for himself in the community. He was not eating properly and began to lose
weight, was not attending to his personal hygiene or clothing, and his apartment fell
into 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 his
apartment. He was investigated for calls related to noise, unusual behaviour and
allegations of sexual assault. He was never charged with any offence.
The deceased’s family and social worker discussed long term care placement with
him and he agreed to apply, presumably so that he would be in a more supportive
setting that could meet his needs.
The Community Care Access Centre (CCAC) assessment for long term care was
completed in January 2005. He was noted to have had recent significant weight
loss, hearing impairment and some cognitive impairment. It was noted that his
mood had become worse over the prior three months, and he had been expressing
feelings of loneliness, unrealistic fears and had withdrawn from social and other
activities. He required full assistance with meal preparation, housework, finances,
managing medications, shopping and arranging transportation. He would not eat
unless his meal was prepared and set out for him. He required supervision for
dressing, personal hygiene and bathing, and limited hands on assistance with
eating. 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 in
February, 2005.
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 23

26. In August 2005, another resident was admitted from the regional acute care
hospital to the LTCH, into the same room as the deceased. The new resident was
a 55 year old man with chronic schizophrenia and evidence of psychopathic
personality disorder. He had a longstanding cognitive impairment, poor memory
and often did not comply with his medication. He had admissions to many
psychiatric hospitals in this province with no long term resolution due partly to his
personality disorder affecting the acquisition of insight into his psychiatric illness.
The new resident had a significant criminal record for property offences, but was
not known to be violent. He did not have any previous behavioural issues with
former roommates or staff.
In September 2006, the resident’s medications were changed as he was felt to be
too sedated. Following the change in medication, his behaviour and agitation
worsened. Several verbal outbursts towards staff were documented. In October
2006, the record notes the first specifically expressed complaint about his
roommate, the deceased. In December 2006, an episode of physical aggression
was noted when he threw a wheelchair into the elevator. There was no aggression
directed at staff or another person.
In December 2006 through January 2007, the resident expressed suicidal ideation
and 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 by
health care aids for both residents. The charts indicated the frequency (but not
severity) of certain behaviours. Accuracy of the behaviour charting is questionable
however as many events noted in other written records were not reflected in the
charts. There are several references in the records to loud verbal conflicts between
the two roommates. Reports indicated that both men initiated the verbal
altercations. Witness statements indicate that most of the verbal conflict consisted
of the men insulting each other. Most of these witness statements indicated that
the conflict happened increasingly in the latter part of 2006.
In October 2006, a health care aide reported that he had to intervene when the
resident was hitting the deceased during an altercation.
In January, 2007, there was a physical altercation between the resident and the
deceased. The fight was over the volume of the deceased’s television. The
resident struck the deceased with his fists and knocked him to the floor. A nurse
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 24

27. witnessed the incident and intervened. The deceased was not breathing and had
no 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 was
comatose, was not moving spontaneously, did not withdraw to pain, his pupils were
fixed and dilated, there were no corneal reflexes, and he had a Glasgow Coma
Scale of 2+2. He was resuscitated and a heart rhythm and adequate blood
pressure established.
A CT scan from the Emergency Room showed no bony fractures, and no scalp or
soft tissue swelling. There was a massive degree of subarachnoid blood
throughout the basal cisterns and both convexity sulci. Blood was noted in both the
third 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 scan
the following day showed diffuse cerebral edema and more blood in the right
ventricle. A CT angiography showed a large aneurysm measuring 11 mm arising
from the origin of the left posterior inferior cerebellar artery. There was
developmental hypoplasia of the right vertebral artery.
Later that day, the deceased was declared brain dead and was removed from life
support.
A post mortem examination was done and the cause of death was noted as, “acute
traumatic rupture of the left vertebral artery complicating blunt impact to the head
and neck.”
A subsequent MOHLTC “Unusual Occurrence” investigation at the LTC home found
no evidence of unmet standards in the care of either the resident or the decedent.
Discussion
This case raises several issues including: the placement of adults with
developmental disabilities in, and within LTCH; placement of adults with severe
psychiatric illness in, and within, LTCH; management of behaviours from a variety
of conditions in LTCH; staff training and risk assessment for physical aggression in
a resident.
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 25

28. Placement of Adults with Developmental Disabilities in LTC Homes
This has been addressed by the Ministry of Health and Long Term Care
(MOHLTC), the Ministry of Community and Social Services (MCCS), and an
advocacy group called “The Ontario Partnership for Aging and Developmental
Disabilities” (www.opadd.on.ca). There is an extensive protocol, developed by the
MOHLTC and MCSS entitled Long Term Care Home Access Protocol for Adults
with a Developmental Disability (July 2006). The protocoal describes in detail, the
process for placement of adults with a developmental disability in LTC, including
the additional supports and care planning for the individual. However, the
document does not address the issue of case mix, or room sharing/geographic
placement within the home for these individuals, except in the case where a large
number 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 staff
of 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 first
challenges in finding appropriate long-term care for older adults with a mental
illness is the admission process. CCACs are not guided by a mental health
mandate.” People are admitted for a variety of reasons, but an individual's mental
illness is very often secondary. Placement is not based on their mental health, but
on their physical mobility issues, other than in the case of dementia. Most LTCH
are designed for people who are physically immobile and not for those with a
mental illness.
There are a number of initiatives sponsored by the MOHLTC to address the issue
of specialized psychiatric services in LTC. These resources however, remain
scarce and almost exclusively focused on dementia.
The RAI-HC (Resident Assessment Instrument – Home Care), the instrument used
to gather pre-admission information, is a quantitative data template that allows
space for qualitative (i.e. narrative) data. The RAI-HC completed on the resident
prior to admission was relatively sparse. It is unclear whether the LTCH was aware
of the offending resident’s full social history, including his anti-social behaviour and
possible psychopathic personality disorder.
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 26

29. The nature and complexity of human health conditions, in particular mental health
and behavioural problems, precludes all necessary information being gathered on a
standardized quantitative assessment like the MDS-RAI (Minimum Data Set –
Resident Assessment Instrument). Even a fully completed RAI-HC is integrated
with thorough information from sources such as the clinicians caring for the
potential resident, and community-social supports who may know the person well.
Information about the resident’s long history of mental health and behavioural
problems may have changed the decision-making of the LTCH in assessing
suitability for admission, and room assignment.
Case Mix in Long Term Homes
Staff in LTCHs are now being asked to care for individuals with a wide range of
health problems. These include the frail elderly, persons with dementia, acquired
brain injury, psychiatric illness, developmental disabilities, and persons with severe
physical illnesses including advanced neurodegenerative diseases. The MOHLTC
has closed over 50% of the hospital-based Complex Continuing Care (CCC) beds
in the province over the last decade or so. These beds were staffed by
professional nurses in staffing ratios that allowed for safe and effective care of
residents with complex needs, including advanced disability and mental
health/behavioural problems. Now, these residents are in LTC homes, where the
nursing and personal care staff are mostly unregulated, and where staffing ratios
are much lower than in CCC. While LTCH in large urban centers can, to a certain
extent, “specialize” in certain populations, allowing staff to develop expertise and
experience with a particular population, this is not possible in smaller urban or rural
centers without moving the individual far from their home community and/or family.
Given the staffing of LTCH, staff cannot possibly become experienced and
competent in caring for the wide variety and complexity of conditions currently
being seen in LTCH, especially when many require widely differing management
strategies.
It is not clear from the records whether the staff in this particular LTCH received any
special training in managing psychiatric illness and behaviours, or adults with
developmental disabilities. Staff may have been more alert to the signs of
worsening psychiatric illness, been better able to assess and manage risk and
behaviours of both the decedent and the offending resident. Physicians should
also be included in training initiatives and they should be supported in developing
specific competencies to care for the diverse populations in LTCHs.
LTCH residents are over age 18, with widely differing diagnoses. Based on their
history and diagnoses, some residents may not be compatible house or
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 27

30. roommates. In this case, a resident with a history of anti-social behaviour and poor
anger management, was placed with a vulnerable developmentally delayed
resident who seemed to have little ability to understand and appreciate the effects
of his behaviour. It is not clear how much information the LTCH received from
CCAC regarding the prior history of anti-social behaviour of the resident.
Alternatives to LTC for adults with psychiatric illness or developmental disabilities
Alternatives to LTC for adults with psychiatric and/or developmental disabilities are
limited. In many cases, the care required for these individuals exceeds the minimal
publicly 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 in
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 28

31. 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 4
Reference: 2008-14016
Issue:
Management of complications of a fractured hip.
History
This is the case of a 77 year old woman who resided with her husband and
received support services from the Community Care Access Centre (CCAC). She
had chronic unsteadiness of her gait and used a walker. She required assistance
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 29

32. for personal care. Her significant past medical history included Parkinson’s
disease, degenerative disc disease, osteoporosis, and small cerebral aneurysms.
On September 24, 2008 while bathing with an assistant present, she fell and
suffered an intertrochanteric right hip fracture. She was taken to a General Hospital,
then transferred to a Regional Hospital where the hip was surgically repaired. She
was given appropriate antibiotic prophylaxis and deep venous thrombosis
prophylaxis. Her postoperative clinical course was uneventful. She was
transferred 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) for
further mobilization. Functionally, she required assistance for transfers, used a
wheelchair for ambulation, required assistance for personal care, but was able to
feed herself.
Diarrhea was apparently first noted at this LTCH on November 1. It would appear
that the diarrhea was initially thought to be due to the Iron replacement medication
that she was taking.
On November 2, 2008, a Continence Assessment Tool made no mention of the
diarrhea. The record indicated that the woman was continent of both bowel and
bladder. This observation was in conflict with information provided by the woman’s
family.
The record indicates that the woman was incontinent of loose, black, watery stool
on November 2 and 3.
She was assessed by the LTCH attending physician on November 3. The
physician acknowledged the presence of diarrhea, as well as the administration of
iron. Further examination revealed the presence of a soft abdomen with no
tenderness and no bruits. Further treatment was not recommended at this time.
On November 5, the woman complained to the Admissions Coordinator about her
stomach trouble and diarrhea and requested to see a physician. Progress notes
indicated that staff thought the medications were causing the diarrhea. Iron therapy
continued and Acetaminophen with Codiene 15 mg was occasionally being given
for pain. Vital signs indicated that the woman’s blood pressure was decreasing and
pulse and temperature were increasing.
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 30

33. On November 6, 2008, nursing staff noted that the woman was very weak, refused
to get up, and had a further loose, black stool. Her BP was 80/50. She was
assessed by the regular house physician who noted that the woman’s husband
stated that she had a bout of diarrhea about one month earlier, but this had
resolved spontaneously. The physician recommended transfer to the emergency
room (ER) for treatment of the dehydration and that stools for C. difficile culture be
obtained 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 was
assessed by an internist as well as by the ER physician. The medical record
acknowledged the presence of two weeks of loose, black greenish offensive stools
about twice daily. She complained of nausea, poor appetite, but no abdominal
pain. 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 antibiotic
use.” Examination of her abdomen revealed right lower quadrant tenderness with
some rebound, left upper quadrant tenderness, no organomegaly, and the
presence of bowel sounds. On rectal examination, “no constipation” was noted.
Treatment included the commencement of intravenous Ciprofloxacin for a
presumed urinary tract infection. She was placed in isolation because of the
diarrhea.
On the morning of November 7, 2008, the woman’s clinical status remained poor
although she was noted to be afebrile. It was noted that treatment with a bolus of
Normal Saline had resulted in an improvement in her BP. Her heart rate remained
elevated at about 135. Over the course of the day, her heart rate dropped down to
the 40-50 range. A CT scan of the woman’s abdomen revealed the presence of
degenerative disc disease and thickening of the left colon and sigmoid raising the
question of an infective or ischemic colitis. She was assessed by an infectious
diseases consultant who recommended continuing the Ciprofloxacin for three more
days and starting Metronidazole in accordance with the C. difficile colitis protocol.
The first dose of intravenous Metronidazole was given at 2100 hours on November
7. She was continued on the intravenous Ciprofloxacin.
The woman died at 0025 hours on November 8, 2008 respecting her “Do Not
Resuscitate” order.
Based on the documentation submitted for review, it is believed that the woman’s
death was due to sepsis complicating the fractured right hip. No autopsy was
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 31

34. performed. It could not be determined if the sepsis was due to a possible urinary
tract 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 the
woman’s illness, it is not certain that a more favourable outcome would have
resulted. Thirty day mortality rates for C. difficile vary widely from 4.7% in 1991/92
to as high as 23% in the hypervirulent strain initially seen in Quebec, but which is
not the predominant circulating strain in Ontario. Mortality rates are strongly
influenced by age and comorbidities. 1
Clostridium difficile is the most common cause of hospital acquired diarrhea in
industrialized countries. 2 From the documentation submitted for review, the treating
health care professionals may not have been sufficiently aware that the woman was
at very high risk (i.e. had multiple risk factors) for the development of Clostridium
Difficile Associated Disease (CDAD). The risk factors for the development of
CDAD have changed significantly over the last 10-15 years. In addition to the risk
posed to the use of antibiotics, other equally important risk factors include:
advanced age, use of proton pump (PPI) medications, recent hospitalization or
residing in a LTCH, and systemic chronic illness. In this particular case, the
woman’s recent hospitalization, use of a PPI, and advanced age should have been
reason 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 have
raised 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 of
her transfer from the General Hospital to the LTCH. A cumulative medication record
may have been helpful in this case. Currently, the province is making progress in
medication reconciliation and this appeared to be effectively carried out during the
woman’s multiple transfers. Unfortunately, this process does not document
medications received previously. The availability of a regionally accessible
electronic health record may have been helpful.
Also of concern was a telephone order that was given for Loperamide
Hydrochloride for the woman’s diarrheal symptoms. This was given in the absence
1
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

35. of an etiological diagnosis for the diarrhea. Loperamide Hydrochloride should only
be used after the cause of the diarrhea has been established and a treatment plan
has been instituted. Loperamide Hydrochloride is known to worsen CDAD and may
increase mortality. 3
When the physician assessed the woman on November 6, 2008, the severity of the
situation was recognized and the possibility of C. difficile colitis was acknowledged.
In Ontario, the current model of care does not financially support frequent physician
visits to LTCHs. Models of care that recognize the increasing activity of illness in
residents of LTC homes and allows for frequent and timely evaluations of the
changing health status of the ill elderly residing in LTCHs in Ontario, should be
considered.
Recommendations
1. 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

36. Case 5
Reference: 2008-7307
Issue:
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 2008
from a residential facility for people with a acquired brain injuries.
In 1987, the man suffered a head injury that prevented him from continuing full time
work. In 2000, he was hit by a motor vehicle and suffered massive traumatic
injuries, including a severe brain injury. He required a prolonged hospitalization
and subsequent rehabilitation, but was left with significant cognitive and mobility
impairment and was doubly incontinent. Other significant past medical diagnoses
included: childhood hip surgery with postoperative osteomyelitis; type II
diabetes 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 was
doubly incontinent, had significant cognitive impairment, and was mobility impaired.
He required supervision with transfers and walked with a walker. He appeared to
eat well and participated in activities.
Throughout his stay in the LTCH, nursing staff noted that the man had episodes of
verbal and physical aggression, often when care was being provided. Firm verbal
communication was usually sufficient to effect control.
In July 2008, the man was noted to have three falls, one of which may have been
associated with a seizure.
In September 2008, nursing staff noted that the man displayed aggressive
behaviour when personal care was being given.
In December 2008, nursing staff noted that the man’s falls were becoming more
frequent and in March 2009, the man pushed another resident in the LTCH.
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 34

37. In April 2009, nursing staff noted that the man was constipated.
In May 2009, the man had an annual physical examination. There were no
abnormal abdominal findings documented. A rectal examination was not performed
at the time of this examination, nor had one been done the year before when he
was admitted to the LTCH.
In June 2009, it was noted that the man had loose bowel movements overnight and
then again the next day. His laxative medications were held. The man’s weight had
decreased 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 his
abdomen was extremely distended. When questioned by staff, he advised that he
had not had any recent bowel movements. He was given Bisacodyl suppository,
then had breakfast. Nursing staff contacted the attending physician who
recommended 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 was
due to acute small bowel infarction as a result of large and small bowel obstruction
from fecal impaction in a man with a remote brain injury (motor vehicle collision)
and significant atherosclerotic coronary artery disease involving the left anterior
descending coronary artery.
Discussion
The Geriatric and Long Term Care Committee continues to see cases where
constipation has resulted in the death of an elderly person. This trend is especially
troublesome given the fact that deaths continue to occur subsequent to the
publication of the article “Constipation Can Be Deadly” in Volume 38 of the
Canadian Family Physician in 1992.
This man suffered from chronic constipation throughout his stay in the LTCH. From
the documentation submitted for review, it would appear that a rectal examination
was not done on admission, or at the time of his yearly physical examination in May
2009. When he developed loose bowel movements in June 2009, his laxatives
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 35

38. were held and again, a rectal examination was not performed. Had a rectal
examination been done in May or June 2009, the diagnosis of fecal impaction with
overflow incontinence may have been made, which may have resulted in a more
favourable outcome.
The man was taking a number of medications known to cause or exacerbate
constipation (e.g. iron, Olanzapine Tartrate, and Lamotrigine). Iron was being
taken, yet there was no obvious evidence of the presence of iron deficiency
anemia. Even if he had been iron deficient at some point in the past, it is expected
he 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% of
patients taking iron can develop constipation.
In addition, the man was taking a large dose of Olanzapine Tartrate during his
entire stay in the LTCH. Lamotrigine may interact with, and potentiate the sedating
effects of Olanzapine Tartrate. According to the CPS, 9% of patients taking
Olanzapine Tartrate can become constipated.
The man’s behavioural problems appeared to be situational (e.g. when care was
being provided). Anti-psychotic medications may not have been the best choice for
the management of a situationally induced abnormal behaviour. Consideration
could 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 of
his life. Of concern was the absence of a thorough medical assessment to look for
a reason for the falls. The increased number of falls may have been related to his
constipation, his medications, or some combination thereof.
The man was on a relatively low dose of Lactulose. It is uncertain if increasing the
dosage of Lactulose, rather than relying on enemas and suppositories, might have
been a more effective treatment.
Recommendations
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.
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 36

39. 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

40. 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

41. Analysis of Recommendations: 2004 - 2009
2004 2005 2006 2007 2008 2009
Total Number of Cases 25 28 27 17 18 20
Reviewed
Total Number of 67 59 71 35 46 39
Recommendations
# of Cases and Recommendations Based on Area of Concern (Note: Cases may have
more than one area of concern identified)
Medical / Nursing Management
Number of cases with area of
concern: 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 / Documentation
Number of cases with area of
concern: 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 Elderly
Number of cases with area of
concern:
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

42. Admission, Discharge and Transfer
Procedures
Number of cases with area of 3 3 3 1 1 0
concern:
12% 11% 11% 6% 6%
% of total cases:
3 4 4 2 2
Number of recommendations:
4% 7% 6% 6% 4%
% of total recommendations:
Determination of Capacity and
Consent for Treatment / DNR
Number of cases with area of 2 2 0 0 0 0
concern:
8% 7%
% of total cases:
1 3
Number of recommendations:
2% 5%
% of total recommendations:
Use of Restraints
Number of cases with area of 0 0 1 01 0 0
concern: n/a 4%
% of total cases: n/a 0 4
Number of recommendations: 0
n/a 6% 6%
% of total recommendations: n/a
Acute and Long Term Care Industry,
including the Ministry of Health and
Long-Term Care
Number of cases with area of
concern: 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

43. Acknowledgements
The Geriatric and Long Term Care Review Committee would like to acknowledge
the efforts of Mrs. Cathy Traynor for her dedicated and invaluable service in the
preparation of the individual reports and the Twentieth Annual Report.
Questions and comments regarding this report may be directed to:
Ms. Kathy Kerr
Executive Lead – Committee Management
Office of the Chief Coroner
26 Grenville Street
Toronto, Ontario
M7A 2G9
Kathy.M.Kerr@Ontario.ca
Geriatric and Long Term Care Review Committee – 20th Annual Report – 2009 41