Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System REPORT The Honourable Eileen E. Gillese Commissioner Volume 1 – Executive Summary and Consolidated Recommendations Volume 2 – A Systemic Inquiry into the Offences Volume 3 – A Strategy for Safety Volume 4 – The Inquiry Process Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System REPORT The Honourable Eileen E. Gillese Commissioner Volume 1 – Executive Summary and Consolidated Recommendations Volume 2 – A Systemic Inquiry into the Offences Volume 3 – A Strategy for Safety Volume 4 – The Inquiry Process This Report consists of four volumes: 1. Executive Summary and Consolidated Recommendations 2. A Systemic Inquiry into the Offences 3. A Strategy for Safety 4. The Inquiry Process ISBN 978-1-4868-3586-7 (PDF) ISBN 978-1-4868-3582-9 (Print) © Queen’s Printer for Ontario, 2019 Disponible en français VOLUME 3 Contents VOLUME 1: Executive Summary and Consolidated Recommendations VOLUME 2: A Systemic Inquiry into the Offences VOLUME 3: A Strategy for Safety Dedication ......................................................... iv Acronyms and Abbreviations .................................... .v Chapter 15: Building Capacity and Excellence in the Long‑Term Care System ...................................... 1 Chapter 16: Building Awareness of the Healthcare Serial Killer Phenomenon ................................... .25 Chapter 17: Deterrence Through Improved Medication Management .................................... 71 Chapter 18: Detecting Intentionally Caused Resident Deaths ............................................. 133 Chapter 19: Suggestions Not Pursued ......................... 173 Appendices ...................................................... 183 Appendix G – A Just Culture Guide ............................... 184 VOLUME 4: The Inquiry Process Dedication Volume 3 of the Report is dedicated to the many nurses and other caregivers who perform their jobs in the long-term care system with great kindness and skill. Our Strategy for Safety cannot succeed without their continued dedication to those in their care. In opening our eyes to the one nurse who harmed, we must not forget the work of the many who are a credit to their professions. Acronyms and Abbreviations v Acronyms and Abbreviations ADC automated dispensing cabinets ADR alternative dispute resolution APR automated provider reports BCMA barcode-assisted medication administration BPMH best possible medication history CAMH Centre for Addiction and Mental Health CCAC Community Care Access Centre CCF complaint, critical incident and follow-up CFS Centre of Forensic Sciences CIAF Canadian Incident Analysis Framework CIATT Centralized Intake, Assessment and Triage Team CIHI Canadian Institute for Health Information CIS Critical Incident System CLRIs Centres for Learning, Research and Innovation cMAR computer-generated medication administration record CMI Case Mix Index CNO College of Nurses of Ontario COPD chronic obstructive pulmonary disease CVA cardiovascular accident CVH cardiovascular heart disease DIOC Death Investigation Oversight Council DNR do not resuscitate DOC director of care DON director of nursing EDB emergency drug box eMAR electronic medication administration record ESPA External Service Provider Agencies Policy ETMS events tracking management system Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System vi Volume 3 n A Strategy for Safety FPU Forensic Pathology Unit FTE full-time-equivalent (employee) HCCSA Home Care and Community Services Act, 1994 HCSK healthcare serial killer HESP Health, Education and Social Policy (Committee of Cabinet) HNHB Haldimand Niagara Haldimand Brant HQO Health Quality Ontario HSARB Health Services Appeal and Review Board HSIM Health System Information Management (Division) HSMR hospital standardized mortality ratio HSP health service provider HSSP Health and Social Services Policy (Committee of Cabinet) IALP Inter-Agency Leadership Partnership I/CAD Intergraph Computer Aided Dispatch ICRC Inquiry, Complaints and Reports Committee IPDR Institutional Patient Death Record IQS Inspector’s Quality Solution ISMP Institute for Safe Medication Practices LHIN Local Health Integration Network LHSIA Local Health System Integration Act, 2006 LQIP Long-Term Care Home Quality Inspection Program LRPA Long-Term Care Home Quality Inspection Program Risk Performance Assessment LSAA Long-Term Care Home Service Accountability Agreement LTC long-term care LTCH Long-Term Care Home (Division) LTCHA Long-Term Care Homes Act, 2007 LTCI Long-Term Care Homes Public Inquiry MAPLe Method for Assigning Priority Levels MAR medication administration record MAR/TAR medication administration record / treatment administration record Acronyms and Abbreviations vii MDS Minimum Data Set MOU memorandum of understanding MPP Member of Provincial Parliament NHA Nursing Homes Act NHP Nurses’ Health Program NP nurse practitioner NPC nursing and personal care OARC Ontario Association of Residents’ Councils OCC Office of the Chief Coroner OCD obsessive compulsive disorder OFPS Ontario Forensic Pathology Service OHIP Ontario Health Insurance Plan OIC Order in Council OLTCA Ontario Long Term Care Association ONA Ontario Nurses’ Association OPA Ontario Pharmacists Association PAC Professional Advisory Committee PFPU Provincial Forensic Pathology Unit PIA Public Inquiries Act, 2009 PICB Performance Improvement and Compliance Branch PICC peripherally inserted central catheter PLP Preceptee Learning / Developmental Plan PME Post Mortem Examination POM provider operations meeting PRN pro re nata (“as needed”) PSW personal support worker RAI Resident Assessment Instrument RAI-CA Resident Assessment Instrument – Contact Assessment RAI-HC Resident Assessment Instrument – Home Care RAI-MDS Resident Assessment Instrument–Minimum Data Set RCPSC Royal College of Physicians and Surgeons of Canada Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System viii Volume 3 n A Strategy for Safety RHPA Regulated Health Professions Act, 1991 RL6 system electronic complaint / incident reporting system (Saint Elizabeth Health Care) RN registered nurse RPN registered practical nurse RPNAO Registered Practical Nurses Association of Ontario RQI resident quality inspection RSC regional supervising coroner SAO Service Area Office SCAN Suspected Child Abuse and Neglect (Program) SDM substitute decision-maker SIU Special Investigations Unit SW CCAC South West Community Care Access Centre SW LHIN South West Local Health Integration Network TAR treatment administration record WHMIS Workplace Hazardous Materials Information System WSIB Workplace Safety and Insurance Board CHAPTER 15 Building Capacity and Excellence in the Long-Term Care System I. Introduction ...................................................... 2 II. Systemic Issues Demand a Systemic Response ................. 3 III. The Current System – A Solid Foundation on Which to Build ............................................................ 5 A. The LTCHA and Regulation .................................... 6 B. The People and Organizations in the LTC System .............. 7 1. Pro-active Stakeholder Initiatives ................................. 8 2. Ongoing Stakeholder-Led Innovation ............................ 11 IV. Building Capacity and Promoting Excellence in the LTC System .................................................. 13 A. Prevention – the Impetus for Change ......................... 13 B. An Expanded Ministry Role ................................... 14 1. Support for LTC Homes in Achieving Regulatory Compliance ....... 16 2. Spreading Best Practices Across the LTC System ................... 17 3. Funding Bridging and Laddering Programs in LTC Homes .......... 18 4. Encouraging Innovation and the Use of New Technologies ......... 19 V. Conclusion ...................................................... 20 RECOMMENDATIONS .................................................... 21 Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System 2 Volume 3 n A Strategy for Safety I. Introduction Based on the evidence I heard in the public hearings, it is my view that systemic failings in the long-term care (LTC) system – not individual ones – created the circumstances that allowed Wettlaufer to commit the Offences. In this volume of the Report, I describe the systemic vulnerabilities identified through the Inquiry processes and propose systemic responses that must be taken if we are to avoid similar tragedies in the future. These responses are designed to prevent, deter, and detect wrongdoing of the sort that Wettlaufer, a healthcare serial killer (HCSK), committed. This chapter is devoted to strategies whose goal is prevention. Later chapters in this volume are directed at the strategies for deterrence and detection. I begin this chapter by considering why systemic issues demand a systemic response. In the next section, I explain that although the LTC system is grappling with serious challenges, it is far from broken. In the section that follows, I call for the Ministry of Health and Long-Term Care (Ministry) to play an expanded leadership role. In fulfilling this expanded role, the Ministry will strengthen the LTC home system through capacity building and the sharing of excellence. I call for a new unit in the Long-Term Care Homes Division to support LTC homes in achieving regulatory compliance and to spread