Ombudsman's report slams Sask. Health Authority in death of long-term-care resident

The Saskatchewan Health Authority (SHA) failed to provide a long-term care resident, who died three days after taking a fall, with the minimum standard of care required by the Ministry of Health's program guidelines for special-care homes, the ombudsman has found. 

Provincial ombudsman Mary McFadyen released her 2021 annual report on Thursday.

The ombudsman's office received 3,811 complaints, 188 of which were about the SHA.

McFadyen highlighted a long-term care investigation about a resident, given the pseudonym Sophia, who had a high risk of falling. In fact, she fell out of bed on her first night but staff quickly found and helped her because her bed alarm sounded, the ombudsman's report says. Additional fall-prevention safeguards were added to her plan.

However, a few days later, Sophia was found on the bathroom floor bleeding, seriously injured and unresponsive.  She was taken to hospital and died three days later.

Sophia could have been lying on the floor for up to an hour and 45 minutes, according to information provided to the ombudsman.

After Sophia's first fall, her care plan was updated, requiring:

As well, whiteboards were set up in her room instructing staff to set her bed alarm, and to help her to the bathroom twice during the night.

Despite having a plan that met Sophia's needs, the SHA failed to properly implement it, the ombudsman found. 

"Her caregivers were unclear whether her bed alarm had gone off, was not working, or even whether it had been activated when she went to bed. No one confirmed that it was working or turned on. They were also not clear about when or how many times she was checked on during the night," the ombudsman wrote in the report.

The ombudsman found no indication that Sophia had been checked on after 8:30 p.m. until 3:00 a.m. — a 6½-hour gap.

"Though there is no way of knowing for sure, she likely fell because she got up to go to the bathroom by herself. Had the bed alarm gone off and a staff member responded to it immediately, she may not have fallen at all," the ombudsman said.

"Even if she had, she would have been found, and her injuries would have been assessed and attended to much earlier."

The ombudsman found that the incident report that staff filled out after Sophia's fall was not completed properly, noting irrelevant things while failing to note things that were important. For example, the form said it wasn't applicable whether the bed alarm was activated.