Speaking Out About Abuse in LTC Homes

By Brenda Pearce, RN

I recently watched the W5 program on abuse in Long Term Care (LTC) homes across the country. If you have not seen it, then I URGE you to watch it right now by clicking this link:
http://www.ctvnews.ca/w5/w5-nursing-home-investigation-reveals-1-500-cases-of-staff-to-resident-abuse-in-one-year-1.2321287

To give some background, I am an Ontario Registered RN with over 3 decades of experience in healthcare. I have taught Personal Support Workers (PSWs) and Registered Practical Nurses (RPNs) at the Ontario College level.  I have been a part of an implementation project with the Ministry of Health and Long-Term Care (MOHLTC) in Ontario, and I have worked in both the hospital sector and to this day have worked in 10 LTC homes. I work as a part time RN in LTC right now. I am writing this blog from a place of knowing. I only speak from my experience.

Watching the CTV program at first blush is very shocking. There are things that happen and are seen in it that should never ever happen. There are actions that people do out of becoming disenfranchised and burned out, and are inexcusable. I feel for the families, the residents and the staff. I too have aging parents and part of my quest of working in so many LTC homes is to eventually find where I would place my parents when and if the time comes. I am still looking.

Many people coming into long term care are very complex. Their needs are escalating as the problem lists are expanding. People are not just the elderly. There is a growing population of younger and younger people who cannot be housed and assisted as home options dwindle and their complexities increase. There are more and more mentally ill people being admitted along with the cognitively and physically declining elderly. The baby boomer population has not peaked yet and as we peak, we will see the co-mingling of people at various states of age and complexity increase.

The focus of the W5 show is on unregulated care providers (UCPs) known as PSWs or previously known as HCAs (Health Care Aides). It shows a variety of people providing damaging, derogatory and disrespectful care. All of it should NOT be occurring. What I want to focus on is the instances of direct care where 1 UCP is providing direct care to 1 resident, or where 2 UCPs are making snide remarks and being directly disrespectful to a resident. Treating these clients like unwanted baggage is totally wrong. I will not justify the behaviour. I will justify that with heavy workloads, decreased coverage of care during times of breaks, where less staff are taking care of residents’ requests and needs are at high demand at times, these behaviours are symptoms of a system based on minimum care standards that are set by our Ministry of Health, and multiplied throughout the country.  In Ontario, the symptoms are magnified from home to home. Some are a little better, but the minimum standards provide homes a benchmark that they often do not exceed as funding by the MOHLTC sets the envelopes that each home receives. Many homes are businesses and as such need to provide profits to shareholders and corporations in order to continue to be in business.  

There are for profit homes, charitable homes and municipal homes. These homes need to be run in the black, not the red. These homes belong to one of two provincial associations. The OLTCA is for profit homes and the other association is for not-for-profit homes. Many residents who come into these homes are filling semi-private and private rooms and have nothing more than their basic pensions. Or they fill these beds in interim until the appropriate level of beds become available. New build regulations in Ontario are doing away with the traditional 3 and 4 bed ward rooms, but many homes have not yet been able to rebuild or implement these changes, or are on a list within their respective corporations to rebuild as able or allowed.

There are standards that must be met to maintain a license to operate. There are annual compliance officer visits, audits, and there are accreditations and generally a lot of hoops to jump through and rules and regulations to remain in the LTC business. A lot of costs are incurred to meet all of these standards of care.

However, the MOHLTC sets the minimum care requirements. They set the funding to these homes, and they set the ratios of UCPs to resident. Homes are going to ensure that the minimums are met, but providing more than that may or may not occur. You can also be assured that there are checks and balances from a corporate level that do not provide incentives to move beyond that to ensure corporate costs and profits are also maintained. In short, the resident is in the middle of this tug o' war. I feel these vulnerable people are being shortchanged, and we are often not aware of this until we are made aware of all of the shortcomings.

There are physical conditions that may make an innocent bump turn into a black eye as the skin tissues thin and the collagen slackens. But, when can an innocent situation and an actual physical contact of abuse appear differently? One only knows. I also know that cognitively impaired people can also become abusive towards a well-intended and compassionate caregiver. Hygiene is a basic requirement of incontinence and goes hand-in-hand with declining cognition. In the W5 episode where the 1 caregiver is trying to turn and attend to the provision of hygiene and applying a brief, I can honestly say that this occurs because of the minimum staff ratio as set out by the MOHLTC. Many residents, minimal staffing and high needs of declining cognitive elderly results in quick care provision and the need to get moving to the next resident as the needs are many and the time to provide care is minimal. It really looks awful on video and, in short, should not have to be this way.

I see the direct care providers in LTC, the UCPs, become burnt out because the high demands of the job. There is also a need to ensure that documentation is complete, and this is extensive. There is reduced staffing while breaks and meals are taken. There are often times that UCPs are working short on shift due to lack of ability to cover call-ins. Why? Many UCPs work 2 or 3 part time jobs in order to afford to live! They may go from one 8 hour shift to another 8 hour shift back-to-back. They may work 10-12-14 days in a row including different shifts, lack of sleep during these long stretches in order to meet the demands of scheduled and unscheduled shifts. There is a basic undercurrent of not wanting to let any of their bosses down. They set themselves up for injury because of the heavy work demands. Different employers under different collective agreements have different levels of pay for the same job. The number of full time jobs is declining because it is more affordable to the LTC homes to move more and more jobs to part time staff. Part time staff that count on the number of scheduled shifts to ensure their income base, take on more part time employers because they cannot count on the call in shifts. Thereby, when a call in comes to them they turn it down as they prefer to go to where they are scheduled, or have a scheduled shift already in place. It is a huge problem which is evident in EVERY LTC home I have worked for. Some employers will not call-out for part-time staff until the 2nd call-in for the shift comes in. This ensures that homes that employ that strategy are always working short. Working short adds more workload to an already overloaded workload based on minimum staffing levels.  

This does not empower the staff to provide the care that they really do want to provide, and when caught on camera as they have been, makes them look like villains, abusers, and criminals. I will not and do not ever feel that blowing ones nose in a sheet, or making out in a room with another staff member, or spraying water on a residents face or throwing them in a chair, or any of these behaviours as seen in the video, are symptoms of the system. They are simply inexcusable. I simply feel that they would be lessened in a system that raises the bar of minimal staffing, where people feel less stressed and have the staffing and resources to provide the care they really do want to provide.

The implementation of a comprehensive assessment system known as RAI MDS was implemented more than a decade ago to improve resident outcomes and provide funding to enable residents to improve abilities through nursing rehab, and to create a team approach from all disciplines. I was part of the Provincial implementation program. Homes were elated to know that by providing more programs to help their residents become healthier, stronger and feel more engaged, they could access funding and create the programs that would increase what is known as the CMI level for each resident. Well, the homes went crazy with implementation, and then the MOHLTC decided that they could not afford to support the implementation of these programs and now there is no funding for nursing rehab, which has led to a significant reduction in the number of programs. 

People who are coming into LTC homes walking are ending up in wheelchairs and losing their abilities, making them frail, more dependent and more at risk for the appearance of abuse during the provision of care. With low minimum staffing ratios, there is less staff to assist people who want to maintain their levels of ability, and the dependency grows.

Turning and positioning frequently for bed-bound residents is the way to reduce pressure ulcers. Allowing better communication and time to provide care to residents allows for better outcomes and reduction of pressure ulcers and provision of care by the Registered Staff who treat the breakdowns, chart and monitor them, and involve the MD in the care needs of the resident. When the ratio on a night shift is 2 PSWs to 60 residents, you can be assured that it is difficult to make frequent rounds to turn and re-position.

This is a growing problem, and not just in Ontario. Here are some solutions:

1. Create a division of the College of Nurses of Ontario to regulate UCPs - Colleges are regulatory bodies that ensure protection for the public.  Each Province has a similar regulatory college.
2. Contact the Minister of Health. Dr. Hoskins in Ontario, or your own Minister in the Province in which you reside.  In Ontario you can connect through this link - http://www.health.gov.on.ca/en/common/default.aspx?hc_location=ufi
3. Demand elected officials and those running for office to be aware of this situation and to lobby for better outcomes for those who reside in LTC, and their families.
4. Be informed well before the time of need to access the system of LTC.
5. Ensure better health outcomes by employing integrative approaches to better nutrition, and employing health practices such as massage therapy, Reiki, reflexology and demanding that these continue well into other health residences, including LTC.   
6. Be active in PRIM, CARP and voice your concerns. Being proactive and advocating for change are very important.