Improving quality and safety in Ontario’s nursing homes

Recent media reports have highlighted the problem of neglect in nursing homes.

Reports from the long-term care sector, in response, have focused on how the quality of care in nursing homes could be improved.

However, measuring the quality of nursing home care can be a challenge.

Rob Sargeant is a general internist at St. Michael’s Hospital in Toronto and cares for patients who are transferred from nursing homes when their medical needs exceed what long-term care staff can provide. Sargeant notes that it is common to see nursing home patients admitted who are clearly suffering from neglect. He teaches medical students and resident physicians to recognize neglect, as well as high quality care, when assessing patients. “I will say to my team, someone out there is doing a great job of taking care of this patient – there are no bedsores, they aren’t emaciated, they aren’t dehydrated, their skin hasn’t broken down from being left too long in a dirty diaper,” says Sargeant.

Earlier this year, the Long-Term Care Task Force on Resident Care and Safety, which was established in response to several high-profile incidents of abuse and neglect, released its action plan. The Task Force, which was chaired by Gail Donner, past Dean of Nursing at the University of Toronto, noted that laws and regulations “are not enough to eliminate abuse and neglect in all long-term care homes.”

But if laws and regulations aren’t enough, what more should be done to ensure that the more than 75,000 people who call long-term care ‘home’ receive high quality care?

Long-term care in Ontario

Ontario has 634 nursing homes, or long-term care facilities as they are technically called. Some are privately owned and managed on a for-profit basis, while others are public and operated by municipalities. Some, mostly private non-profits, specialize in providing care tailored to the needs of specific cultural or religious communities.

The Long Term Care Homes Act sets out more than 400 criteria to ensure that all nursing homes provide good quality care. However, there is increasing concern that nursing homes need to do more than meet regulations in order to meet the increasingly complex needs of long-term care residents.

Donner suggests that neglect “is happening across our society – and its not because of bad people, bad homes and bad regulation – rather, some of this is happening because we aren’t paying attention to the increasingly complex and changing picture of the elderly in our communities.”

Most nursing home residents have some form of cognitive impairment, such as Alzheimer’s disease, and some are occasionally aggressive. Older, medically complex patients with cognitive impairments can be very difficult to care for, and require specialized care to manage their medical, social and behavioral needs.

Andrea Gruneir, a researcher at Women’s College Hospital Research Institute, argues that long-term care in Ontario was not designed to meet the needs of this complex population. She says that “the way long-term care is staffed and resourced needs to change.” This is echoed in the Task Force findings, which asked long-term care residents, staff, family members and volunteers “What kind of things lead to abuse and neglect?” The first response was the quality of work life for staff, including workload, recognition and support and staffing numbers.

While the Long-Term Care Homes Act mandates that nursing homes have a nurse on-site 24 hours a day, 7 days a week, there is no provincial requirement regarding what the minimum staff-to-resident ratio should be. A 2006 research report commissioned by the government of British Columbia found that residents who live in nursing homes with higher staff-to-resident ratios are less likely to develop pressure ulcers. Presumably, more staff means that residents who are immobile can be repositioned more frequently.

Measuring nursing home quality

Health Quality Ontario, an arms-length government agency, was tasked in 2008 with measuring and reporting to the public on the quality of nursing home care. Click on the image below to see the current measures of quality for Ontario’s nursing homes.

While Donner suggests that these indicators are “a good start” , but there is a need to “raise the floor” when measuring the quality of care in this sector. Rob Sargeant suggests that further measures could be put in place to ensure that frail elderly residents are receiving appropriate medical care, including measuring processes of care like having regular discussions about end of life treatment plans as well as regular medication reviews, especially after a resident has had a hospital admission or emergency department visit

Donner agrees, noting that the Health Quality Ontario measures for safety are focused on what happens when things go wrong, and we should also measure what needs to happen for things to go right.

Donner suggests that outcome measures that focus on adverse events do not provide a full picture of quality of care in the sector. “People will fall in long-term care,” she says. “Sometimes its due to erratic behavior, other times its because they were taken to the bathroom, no one checked in on them and they were left sitting for too long and they fell struggling to get up.”

Samir Sinha, the Director of Geriatrics at Mount Sinai Hospital and the University Health Network, as well as the Provincial Lead for Ontario’s Senior Care Strategy, says that while it is important to ensure that environments are safe and minimize the risk of falls, the way we measure falls should not lead to unintended consequences. If homes try to reduce falls by keeping residents more confined to their beds, there will be negative health consequences, and it is important to balance risk with quality of life for residents.

Sinha argues that “there is a danger in only looking at outcomes such as falls and pressure ulcers, because with very complex patients there is a higher risk of these complications – and we do not want to select indicators that would make homes shy away from meeting the challenge of providing care to patients with higher needs.”

Sinha also notes that an important way to measure quality, which is not yet formally captured in Ontario, is by assessing resident and family satisfaction. Andrea Gruneir agrees. She says, “I think that there is a lot of emphasis on technical measures, rather than the residents’ experience.” Surveys of residents and their families would also allow nursing homes to focus on improving quality of life rather than simply reducing the rate of adverse events.

Others have noted that measuring staff satisfaction is another good way to assess nursing home quality. A large staff survey was recently piloted in 400 nursing homes in Ontario as part of the ‘Determinants of Quality in Long-Term Care’ study led by Walter Wodchis at the University of Toronto. The assumption behind this study is that “quality of care is largely dependent on the quality and effectiveness of staff delivering care” in nursing homes. Suzanne Dugard, a spokesperson for Health Quality Ontario, notes that their organization is a partner on the study, and is working on options for publicly reporting staff satisfaction data in 2013.

Improving nursing home quality

One Ministry of Health and Long-Term Care official who spoke with Healthy Debate  noted that “long-term care is a huge, expensive piece of social infrastructure” and that increasing staffing ratios across the board in the sector would be very expensive.

The official noted that “we have 77,000 almost identical beds in nursing homes” but that patient needs vary. Many experts, including the Long-Term Care Expert Panel struck by the Ontario Long-Term Care Association, believe that specialization of beds would improve overall quality. For example, some nursing home beds could be dedicated to people recently discharged from hospital with more medical needs, while others could be dedicated to those with aggressive behaviours.

Catherine Richards, whose mother spent the final months of her life in a Toronto-area nursing home agrees that “neglect is prevalent across long-term care and what it really comes down to is how much time people have [to provide direct care].” Without meaningful data regarding staff, resident and family satisfaction, it is very difficult to know whether nursing homes in Ontario are providing good quality care or not.

The comments section is closed.

  • Mark Ashley says:

    What You Fail To See Isn’t Your To Control Let Us Be !
    It’s true what life is supposed to be As I see the world spins around in such perfect harmony.
    Yes to see how God has made it possible in every way , so that in each year we all get what is the same ?
    Equality of such light and darkness as it matters not where you live north south east or west it’s all the same my neighbours and friends .
    Well maybe it did not occur to you to know see or care ,how it’s his plan to understand the quality’s of his light is to enhance owner very life.
    Although it’s not true time doesn’t go by faster, it only seems too the older we get what amazes me that certain people assume such control.
    What’s even harder to see is that these people think that there’s not a power that’s above them , as this planet lived and breathed long before we came to be.
    Yes no different then you and me , for hundreds of millions of years so , tell me please who you think you are to steal my time as you lie and make my mother cry.
    It’s a shame all the Vanity Vanity just continues To grow as it’s purely insanity as its definition describes you push my buttons to make me look violent no I’m not.
    The very much in dispute of such Constitution and charter of rights as you and trap and neglect and to deny all such Possibilities as it’s your the one out of line .
    In fact it’s beyond sadness and cruelty it’s a new type of school, it teaches theories of control which comes from fear and expresses no love it’s clear.
    For sure I thought is man’s best advantage it can’t come without says success for each and everyone in the same way if you think somebody has to pay that’s wrong.
    Some people call me crazy violent dangerous oh that’s true that’s what they say but they really haven’t got a clue because I act no difference then anyone of you could act if you were forced to know and live as they deprive me each day .
    For thought was a man’s best attribute imagine what it is if those wishes goals dreams strategies desires fails to be something positive think hard please.
    For an all truth an honest truth one that blocked from view from most of you as the source of the problem escapes your very reality it’s a certain blatant misunderstanding that needs to be brought into the light.
    Four in all truth and honest truth when those blocks from view from most of you as the source of the problem escapes your very reality it’s a certain blatant misunderstanding that needs to be brought into the light.
    For it is true we’re all human beings each and everyone with the ability to conceive and believe or not you have the choice to make make it wisely I ask.
    For as it is I know The Latin meaning of choice is sacrifice ended upsets me every day to think of somebody else makes decisions and choices that sacrifice my love my time and the deer love of my mother so fine.The Latin meaning of choice sacrifice end it upsets me every day to think how somebody else makes decisions and choices that sacrifice my love my time and the dear love of my mother so fine.
    For today is a day so special and good it was the birthday of my brother who was taken away another choice another action one with out any satisfaction.
    To think I was involved so many innocent people to see how it’s so difficult to believe my awareness is the neurotic anxiety for you to not conclude how it’s involved each and everyone of you in such a negative way.
    As I see restrictions put on conditions denial put on freedom the best gift in the world to ever give and receive is time I do believe.
    Yes it is I’m human just the same no different than you I claim a sinner I love her a fighter for life and friend stop what you do because you’re infecting Waymore than a few in fact it’s so wrong you can’t even see what you do.
    Yes all that we’ve asked for was nothing from you was only to live and enjoy life and grieve the loss and forgive search crime it’s only Hope with a little time to spare as I try to escape the fear of such brother And friends that can’t see what they do.
    For an all of such beauty and kindness in gods divine glorious way, you must not just continue this way, there’s nothing positive there’s nothing good to come of it it’s clear it’s a crime that continues and his power and control from fear.
    Yes it’s a course of destruction and death to mankind how can you not know and see how forgiveness awaits you at such time please today tell your head and pray and ask God what he needs you to do for him for it is his planet and its time we Must see.
    Yes it’s a course of distraction and death to mankind how can you not know and see how forgiveness awaits you at such time please today bow your head and pray and ask God what he needs you to do for him ?
    If you think it’s not just ours to enjoy together shame on you for it is his plan and His planet it’s time wePLAN IT Please and stop the abuse it’s killing us all .
    I am just passionate trying to be a Friend today for my mother who needs one more then you know stop what you ignore and stand up for hers and mine freedom which is in turn all of yours too if you care to know the reason for life it’s to give not take , I am sorry if I have upset any one it’s never my intention to harm or make feel bad . Rather just allow such truth to be see clear to live again in a simple way is all I ask , Please before it’s too late how could anybody think I would want to hurt my mother it makes no sense there’s no reason she’s the most beautiful person and friend I could ever imagine anybody to know . The very law states in any case That might be considered abusive to ask the person himself what it is they want she’s not out of her mind at least I hope not but she will be in time if you don’t intervene.That might be considered abusive to ask the person himself what it is they want she’s not out of her mind at least I hope not but she will be in time if you don’t intervene. Happy birthday brother Todd I miss you the same today as every other day and I only remember the good times the rest we’re just learning keep your stick on the ice brother love you..Happy birthday brother Todd I miss you the same today as every other day and I only remember the good times the rest we’re just learning keep your stick on the ice brother love you.

  • Mark Ashley says:

    I’ve been given a letter from a manager at Westmont retirement home stating I can’t come on the property so my mother lives there and has for five years I’m not on any court restrictions my brother doesn’t want me to go there but he’s got a biased opinion that she’s manipulating her money and deceiving her and it’s elder abuse and if you can prevent me from finding out from her then she can continue to get away with this crime it’s absolutely pathetic and the police come every time I need to charge me to trust passing and now I have a court date tomorrow on 18 November in Kitchener Ontario under peaceable possession of property my mother is entitled to see whoever she wants she’s the one in control she’s allowed to live in risk do I don’t put her at risk my brothers changed everybody that I’m a violent dangerous villain of whatever nature but have no violence in my past

  • Judy Cohen says:

    1. My 6 years experience (still ongoing) as the wife of a husband with Alzheimer dementia in a long term facility, considered one of the better ones among the 11 administered by the city of Toronto, is that the quality of care by the PSW-s is uneven depending on individual attitudes and skill of the worker and there is no ‘quality control’ by anyone as far as I could ascertain during all those years. Who watches how a PSW performs in the room, alone with a resident? That is why when I noticed wrong treatment to my husband I took photos immediately to prove my point with the appropriate manager. As they say a picture is worth a 1000 words.
    I knew more about each PSW-s quality (or sub-quality) performance who attended to my husband than the floor nurse-manager.
    2. I also found lack of coordination of information between the shifts as they change. Few PSW-s ever look at a resident’s day-care-plan and when attend to a new resident, unless specifically briefed by the attending RN or NM they have no idea if there are special needs to be attended to with that newcomer. Thus, mistakes can be made.
    3. My advise is that it should be mandatory to install hidden cameras in every room in a nursing homes to prevent much of the abuses that might happen otherwise.
    4. Just like teachers have PD (professional development days) so should PSW-s to increase their understanding of the very important work they do, being “front-like soldiers’ in the care of an elderly resident and their keen observations on any changes with the resident should be timely reported.
    I’ll end here although I have many other thoughts on the pros and cons of how nursing homes function with room for much improvements.

  • Rodger says:

    My father is a place with a low ratio and still have nonsense because there is no accountability in our health care system. documentation is often inaccurate. my father can sit for 5 hours and not be repsoitioned yet the nurse will document being repositio ed every 2 hours. The assumption is always that they are professionals and know what to do. Often find nurses sOcializing and ignoring patients..complaining does not help because the organization retaliates against the patient and family. Government agencies do nothing all claiming other organization is responsible .

    Families should be allowed to put in video cameras…so etching likerogers home monitoring


  • Ann Croft says:

    My husband of 53 years was just admitted to a LTCH in Ontario. I am handicapped and found out too late they will not allow me to use my Go-Go electric scooter in their home so I can no longer visit my husband and he will die of lonleyness. I use my scooter as my main source of transportation to get to the home 4 blocks from my apt. This is cruel to both my husband and me. They allow residents to use electric wheelchairs which go 5mph and my go-go top speed is 4mph. This is discrimination. By law are they allowed to have this rule.

  • Patricia Bayley says:

    My Mother ricia is in Orilia On…
    The topic for me is the lack of care or interest in the seniors. My Mom has been in a nursing home for almost 5 years. Two weeks ago she fell and fractured her knee. Was independ to a point before this. Now she is at the mercy of the staff. Not going well in this short period of time has a stage 2 bed score
    I have talked to the managment there…….. No luck, we have a lady helping Mom withat w her breakfast. The staff dosen’t have time to help heanks r. She feed herself before the fall. She used the toliet with help before also. Now when she needs the extra help no one is there to help. I have noticed people that have always needed extra help still get it. Our doctor has wrote orders for the care but no one is doing it. Dont know what way to turn. Anyone know of something to try.


  • Laura Cory says:

    My mother, who is 85 years old, resides at a nursing home in Windsor ON. There is not enough staff to deal with the individual needs of residents. The residents are given many fluids to drink and, therefore, require frequent trips to the bathroom. With only 2 PSWs per floor, this is very difficult. Also, with only 1 nurse per floor, it is difficult for family members to communicate medical concerns because the nurses are preoccupied.
    My mother has been going through a vicious cycle of high blood sugar levels and recurring bladder infections. I took her to a naturopathic doctor a few days ago to receive prescriptions of supplements to address these serious problems, which conventional medicine has been unable to treat successfully.
    The Remedy’s RX Pharmacy refused to fill these prescriptions because they do not understand the safety of the supplements prescribed by a naturopathic doctor. If you seriously want these residents to have a good quality of life, you will encourage integrated medicine and subsidize the cost of supplements for seniors. They have very little money left after paying the high rent at nursing homes.

    • Dee says:

      UTI are probably due to not being cleaned properly.

      Believe it or not many don’t change gloves or after cleaning behind touch front.

      I had a similar problem until I figured out the real problem….eventually it did get rectified.

  • melissa says:

    i have some one who is in a long term care home in north bay the nurse were he lives is taking his stuff away moved him to a different room dose not have and when they moved him the told him he could not have a dresser in his room they jumped him be for explain him self and no one wants to do nothing about it i have talk to a lot of organisation about this and no one wants to help.

  • Redtroika says:

    Nursing homes should also have naturopathic doctors on staff and qualified geriatricians who also practice alternative medicine. Doctors should not have control over patients care unless agreed. Patients should be able to choose their doctors. Many staff are foreigners or early immigrants who may not be the best qualified. Some are good some are not so good. Iv treatments should be allowed in all nursing homes at the patients/residents request. Nursing homes should not be owned or controlled or influenced in any capacity by pharmaceutical companies or where there is a conflict of interest in care or treatment.

  • Zoe Patmanidis says:

    Zoe Patmanidis, Family Council Chairperson
    There is a Greek saying, “the fish smells from the head”. The quality of care is as good as the initial strategies, standards, policies, terms of reference, guidelines, measures, accountability guidelines and ethics, are put into place. It starts from the top. From there changes can be made to enhance quality of care. My mother is in a nursing home. For one year my sister and I have been fighting the establishment for better quality of care. We have been met with resistance WHY? We have dealt with tresspass orders, Capacity Board Hearings to revoke our POA, Care Plans not up to date, staff not following care plans, staff working in wrong disciplines, nurses poorly trained, unserviced equipment.
    My decision to get involved with Family Council was made because I saw the need for families to get educated and involved and have a voice with the quality of care. We all forget that we will eventually get old and if we live long enough we will have a need of some form of care. Why should we not give our elderly the same health care that we would expect to have.

  • lois says:

    how about using your common sense. what is the ratio of staff and children in a daycare? The elderly needs are much more complex than a child but the care for the elderly in nursing homes is deplorable. 2 PSW’s for 30 plus residents. I worked in a nursing home for 40 years and the residents had better care in 1973 than they do now. (just retired 2 years ago) hard to sleep at night living with such guilt. Impossible to care properly for these poor old lovely people.

  • Marilyn Seabrook says:

    There are some great ideas expressed in this document. Having worked in Long Term Care for 20 years now as a nurse, I can tell you the type of resident’s now being admitted are extremely frail, palliative or have major dementia with behavioural issues. Presently there are no ratios of patients to staff, and the funding is inadequate to meet these patients needs. In the home where I work we have one PSW for 9 resident’s on a locked dementia unit. Totally unacceptable to provide appropriate and timely care to this special group of patients. In addition there is one nurse for the entire floor of 28 residents. What is needed to ensure proper care, dignity and patient, family and staffing satisfaction, is adequate amounts of staff to complete necessary care for these clients.

  • Claudette Chase says:

    This is a topic near and dear to wherever PTSD sits in my body. 13 years ago I was injured in a serious car accident. I couldn’t go to rehab until I could weightbear but was too well to stay in an acute bed so my insurance paid for me to stay in a fancy new nursing home. My family was assured they had adequate staff to care for me…the reality was there were many nights that 1 RPN was left to cover my floor and the locked ward for demented patients…I kept my cell phone clutched in my hand at night in case of fire…beleiving my family would get to me before the staff. One night I called for a bedpan and the receptionist came to help as the 1 nurse was tied up. “Which way does it go” she asked. I routinely waited for pain meds but the nurse with alcohol on her breath handing me a soiled face cloth to wash my face was the lowpoint. When I said, “sorry, I think this is the cloth you used to clean me earlier”, her reply was “I rinsed it”. Did I complain? Absolutely not. I felt incredibly vulnerable and afraid of repercussions. As Catherine Richards says, “The fear of repercussions against complainants is a big deterrent for vulnerable people when considering how to approach quality of care issues.”
    There should be a minimum of biannual unannounced inspections and they should include night visits. Thank you for raising this issue.

  • Home Nurse says:

    This is a really good post. Must admit that you are amongst the best bloggers I have read. Thanks for posting this informative article.

  • Home Nurse says:

    Hello there, I am so excited I found your site, I really found you by error, while I was researching on google for something else, Anyhow I am here now and would just like to say kudos for a fantastic post and a all round thrilling blog (I also love the theme/design), I don’t have time to go through it all at the moment but I have saved it and also included your RSS feeds.

  • Judy Filipkowski says:

    Like Karen Copeland, I too have MS. I was fortunate to have been treated for CCSVI with the use of angioplasty outside of Canada and the Province of Ontario. Of course all expenses are mine and so is the aftercare (again I will have to go out of country to receive it).
    Also like Karen, I am a senior, I have no siblings or children to ensure that I am being properly cared for, should I require the services of a nursing home.
    I will make sure that should I reach the stage that if my MS decides to again disable me, I will not stay in Canada but rather go to a country where I can ensure that I have access to a caring death than to life at the hands of uncaring individuals. I will not remain in my trapped body to endure an undignified life when I can have death with dignity!

    And the question asked is WHY – why do I have to leave Canada to ensure dignity in life and in death!

  • Karen Copeland says:

    I am elderly and I am disabled with MS. Also I do not have any family nearby to discover what is wrong with where ever I end up as I surely will. Furthermore, the Ontario government has recently cut my pension back to where I can no longer afford some of the extras this condition requires. Add to that the fact that the Ontario government refuses us the one (at present) treatment that can help and that is there for every other Ontario resident who does not have the letters MS on their file. We are discriminated against before we ever get to the point of nursing home care and I am very sure that since neglect and abuse are there already, we will just get more of the same once there.

    Having worked in nursing homes years ago and having watch the RN in charge step on the insteps of patients to make them do what she said, I am well aware of what goes on inside those homes. Ever had your instep stepped on by someone wearing those heeled granny shoes they used to wear? She was the role model on the ward too. WOW! I really am looking forward to that fast approaching day – NOT! BTW I got fired for treating my patients like real people and it was, and the pink slip still says “unprofessional”. Surely there are young people out there with some morals and humanity that they can hire? To me that would be far better than someone without but having a piece of paper saying they had their RN or RNA. The hiring process should be revisited. And for people like myself, without family here, there should be a Medical Ombudsman for nursing hoes and hospitals. And here is a blast from the past, how about taking nursing out of the universities and putting it back in the hands of the hospitals where trainees can get some hands on experience? Book learning is good for some things but not for interacting with real patients.

    If we have so many unemployed people in this province, why is it so difficult to get decent staff? It shouldn’t be. If our Minister of Health knew what she was doing, this might be less of a problem. But she clearly does not and this became very obvious when I tried to get a mobility scooter while on O.D.S.P. A mobility scooter costs about $4,500.00. But the outlet that she approves – Canada Care – prefer to sell the government $10,000.00 electric wheelchairs that are difficult for people to drive if they have conditions such as arthritis or numbness (as is often the case with MSers). Aside from being outrageously expensive, they are often unsafe as they have a habit of tipping and sending the patient out on their face if they hit a bump on a slightly downward sloping surface. I spent three months fighting The Health ministry to get the more stable, more useful scooter. Go Figure! Their coffers are bare? I can see why. In this OHC building alone there are at least 10 of these chairs often when scooters were requested by both patient and doctor. That could have been a saving of $55,000.00 just here. Imagine the savings if this were province wide. That is $55,000.00 that could be spent on better nursing home staff or equipment. In fact,ask about this separately one time and I will tell you about the other,lessor scams Canada Care with the governments approval have pulled. It is scandalous!

    Well now I am stressed out and stress and MS do not get along very well, so I am off.
    Very Sincerely
    Karen Copeland

    • Lorna McGann says:

      Reading all of this, I find myself hoping the following. That should I eventually require long term care as an elderly person, I will hopefully end up residing with my son. He & his partner are planning to begin a family soon, he told me that I will never be alone. I would be willing to help with child minding, sure that would help.

      As to CCSVI, tested fall 2009, I am still one of the forgotten medical refugees. My current hope is that science will advance to the point where we will get vein transplants. No worry about re-stenosis. What on earth in Canada waiting for? Pretty sure that there is just too much money involved with the MS drugs, the drugs that often don’t work.

      What type of aftercare is needed?

      Lorna McGann

  • Catherine Richards says:

    Andreas Laupacis, I appreciate your comment about the importance of family involvement when a loved one is placed in a nursing home. I’m glad your mother’s involvement was able to make a positive difference for your father in his last few years of life, yet I wonder why any of us feel it is acceptable for frail seniors to receive the bare minimum and “barely adequate” care?

    My late mother’s experience and mine was quite the opposite to that of your late father’s. I still advise people to be as involved as possible with their institutionalized loved one, as ideally one would think it could only help even though in my experience with my mother in her nursing home, my daily visits and constant advocacy for her served only to put us both on the radar of the long term care home’s unscrupulous management team and some equally unscrupulous staff. I lodged formal complaints via the MOHLTC, and today, more than a year and a half since my mother died, my complaints remain unresolved.

    The people at the nursing home did not welcome my observations or comments about my mother’s care or the neglect I tried to identify regarding her repeated infections and a lack of adequate water for my mother to drink, among other issues. My mother had mild dementia and needed regular reminders and active assistance with drinking water and because she had been on Lithium for 30+ years, she needed more hydration than the average person. I could not inspire staff to accept or retain this fact or respond accordingly despite trying daily to do so.

    My mother’s symptoms associated with recurrent urinary tract infections caused her to become increasingly confused and disoriented. When I would alert staff to any of her symptoms they would dismiss my concerns and explain away my mother’s agitation by saying it was her progressive dementia, and yet I encountered only one staff member during my mother’s five and a half months in care that had any education or trusted experience with this condition. I was bullied and intimidated by some of the management and staff whenever I challenged their assumptions about my mother’s health or the quality of her care. The stress was enormous and the frustration of trying to get help for my mother, even from the MOHLTC, was a fruitless endeavour.

    The doctor and registered nursing staff at the nursing home were not made aware, until a year after my mother’s death, that she had in fact been underhydrated for the better part of her last three months on this earth, a fact that was finally unearthed after much communication between myself and the MOHLTC performance and compiance branch inspired a re-inspection into my documented complaints about the neglect my mother fell victim to in the nursing home. Of course, there is so much more to our story . . .

    Basically, when we place a loved one into a long term care home we should be able to trust that they will receive consistent quality care and that when they or we as family members have concerns that we have a safe place to express them. The MOHLTC has a long distance to travel to convince the public that they are willing to enforce the law to ensure that each and every LTC resident is the recipient of quality care. When it is brought to their direct attention that a resident is being neglected, the MOHLTC must do all in its power to protect the resident first and the family who reports such issues in confidence.

    It is not because families are not involved with their loved ones that neglect is permitted to happen without consequence, it is because those with the power and presumed skill to address these complex issues head on refuse to listen to the truth when they hear it. Neglect of completely dependent people in long term care homes is inexcusable and it’s about time those responsible for it are held to account.

    Catherine Richards,
    Cause for Concern: Ontario’s Long Term Care Homes (Facebook)

  • Andreas Laupacis says:

    Two unrelated comments.

    First, this story has personal resonance with me because my dad spent the last 3 years of his life in a nursing home in Ottawa. His care wasn’t as bad as that described by “nursing home doctor”. However, the only reason it was barely adequate was because my mom visited him every day and advocated for him, and dad had a terrific family doctor who ensured that when he got ill he was not transferred to the hospital, and he was allowed to die from his pneumonia in the nursing home.

    Second, the terms we use in health care are very revealing. When patients develop bedsores in a nursing home, we call this “neglect”. If the same patients develop bedsores in an acute care hospital, we talk about them as “opportunities for improvement” and we get the “quality improvement” teams involved. Why the marked difference in terminology for essentially the same thing? Why do we call a spade a spade when talking about quality of care in nursing homes, but not in some other sectors?

    In a similar vein, I have often been struck that pharmaceutical companies, those who regulate drugs like the FDA and Health Canada, and many physicians talk about “drug safety” when they are really talking about the harms and side effects that drugs sometimes cause. A quick search of the web using the term “drug safety” revealed the following: 1) a site called “Drug Safety Canada” that says on its home page “Given the staggering number of deaths associated with adverse reactions to prescription drugs, we are urgently seeking funding to research solutions to this national and international emergency” and 2) a site that says “The FDA evaluates the safety of drugs by looking at side-effects…”. Wouldn’t it be more accurate to call the first site “Drug Harms Canada”, and for the second site to say that the FDA evaluates the harms of drugs by looking at side-effects?

  • Camilla -- geriatrician says:

    It’s unfortunate that many do not prioritize the quality of life of our vulnerable elders until a family member is directly troubled by the situation. Evidence-based medicine and bureaucratic metrics serve to satisfy the care providers and administrators and blind us from what compassionate care should be: a system that attends to personal preference and values.

  • Natrice Rese says:

    The above comments are right on! Our vulnerable and elderly deserve better care and more of it! The work load given to front line staff is impossible to do! Who pays the price ? The clients who cannot complain!

    Ratios of residents to staff is outrageous. Work load, paper filing,meal duties, tick sheets filled out, standing and waiting for someone in charge to sign out a brief or tube of cream from a locked cupboard – pointless waste of everyone’s time , leading to increased discomfort for residents and stress load on staff.

    I hear from psws in the field of the continual shortages of staff – this is common and throws the Ratio out the window! It’s more the norm to work short staffed than full staff!

    Let’s deal with our elderly in a more effective manner ! I want to due with my boots on rather than soaking in my bodily fluids and with pressure sores from lack of positioning!

    It’s a real tragedy what goes on behind the nursing home doors – and it’s time for Ombudsman oversight!
    Not to mention group homes, hospitals and retirement homes

  • Catherine Richards says:

    Thank you Karen Born and Irfan Dhalla for your in-depth coverage of this important topic.

    First, I want to stress that I think measuring quality is a useless waste of time and money if we are dependent mainly on those providing the care (long term care home management and staff), and those gathering and interpreting the statistics (i.e. government: Ministry of Health and Long-Term Care (MOHLTC), and Health Quality Ontario (HQO) to honestly report, genuinely understand and actively address the real problems that exist in long term care homes.

    I agree with Samir Sinha and Andrea Gruneir’s viewpoints: “ that an important way to measure quality, which is not yet formally captured in Ontario, is by assessing resident and family satisfaction. Andrea Gruneir agrees. She says, “I think that there is a lot of emphasis on technical measures, rather than the residents’ experience.” Surveys of residents and their families would also allow nursing homes to focus on improving quality of life rather than simply reducing the rate of adverse events.” but I don’t think it’s an either-or approach, as I assert that by improving quality of life the rate of adverse events would naturally follow.

    I wonder why the MOHLTC or indeed the HQO has not yet captured, assessed and shared with the public, as promised, an accurate picture of long term care from the residents and families’ perspective. Why are the voices of those most affected by long term care kept in the shadows of silence?

    We need more anecdotal information as revealed by residents if capable, or by families/advocates when not, and these invaluable sources of information should be listened to and respected as among the most credible indicators regarding quality of care in long term care homes and hospitals.

    How many people complain about quality of care issues just for the sake of complaining? I assert that very few people encumbered by illness and their families who love them have the time or the wish to complain frivolously. People complain about neglect and abuse when their complaints have merit.

    Most people living in long term care homes enter these institutions out of necessity, not desire. They expect to receive quality healthcare, as do the families who entrust the care of their loved one to a long term care home or hospital. So very often their most basic expectations are not fulfilled and if they decide to complain, there is always a risk of escalating the situation rather than encountering compassion and finding solutions.

    The fear of repercussions against complainants is a big deterrent for vulnerable people when considering how to approach quality of care issues. Another discouraging impediment to improving quality of care is that when complaints are bravely made to a long term care home management or staff and/or the MOHLTC, rarely does anything of value occur to resolve them. The long term care companies in my opinion receive far more consideration and protection from the MOHLTC than any resident or family member. The Long -Term Care Homes Act, 2007 (LTCHA) has myriad rules and regulations, but if there is weak enforcement by the MOHLTC, and the long term care companies receive no real consequence for their role in the neglect of vulnerable people, how can the public trust these institutions to measure their own performance? And more importantly, why must we?

    Why did the government recently dismantle the Annual Inspection protocol for long term care homes? If the government was truly concerned with quality of care and addressing concerns about resident neglect and abuse, they have a strange way of communicating the message. In my opinion based upon my experience and that of others, quality of care will be improved only when the government listens to the voices of those suffering and acts upon the information; when the government pays attention to the public cries for more and better qualified staff on hand to do what is now impossible to accomplish, and when the government finally wakes up and gets out of bed with the long term care companies and their lobbies and allows residents and families to be their accurate measuring stick about the quality of care they depend upon to maintain their quality of life.

    Though it does not shock me, it still upsets me to read the MOHLTC official’s response to the question of measuring and improving quality care for long term care residents (measurements that include well-documented issues of neglect and abuse) . ‘ “long-term care is a huge, expensive piece of social infrastructure” and that increasing staffing ratios across the board in the sector would be very expensive.’ .. And … “but that patient needs vary.”

    Sorry to inform the government – yet again – but the immeasurable emotional price residents and families are forced to pay for its deplorable passivity on this issue far exceeds any cost to the public via taxpayer contributions.

    I don’t have a degree in geriatrics, nor am I a healthcare worker, but through my late mother’s and my personal experience with the long term care system, through my Facebook group, Cause for Concern: Ontario’s Long Term Care Homes, and from being made aware of the experiences of countless people whose stories of neglect and abuse are valid and legitimately heartbreaking, I consider those of us whom have lived to tell our stories, and those of our loved ones whose lives are lived, and some sadly ended, and punctuated by neglect or abuse, we have as much, if not more, expertise on the matter of quality of care than all the statisticians, politicians, and pundits in the province!

    Is anyone with the power to make change willing to finally listen and to act in the best interest of the most helpless?

    Catherine Richards,
    Cause for Concern: Ontario’s Long Term Care Homes (Facebook)

    PS: Please ask your MPP to support the Push for Mush campaign to increase the mandate of the Ontario Ombudsman to oversee long term care homes and hospitals. While I disagree with the commenter, nursing home doctor, about increasing staff ratios in long term care because I do believe more staff is necessary to improve quality of care, s/he is correct in saying that the problems in long term care homes are not isolated, but rather they are systemic issues that are begging to be assessed by a completely independent party, hence why I strongly support the Ontario Ombudsman’s desire for oversight of the healthcare sector. I trust that the Ombudsman’s methods of measuring quality of care in long term care homes would result in the beginning of meaningful and accountable change.

    And one last PS: Rob Sargeant we need more observant medical school teachers and sensitive people like you in this world!:-) Teaching others to identify and recognize the telltale symptoms of neglect of vulnerable people in long term care homes helps break down the wall of denial that often leads to further neglect. Thank you. You and those you teach give us reason to have hope for the future.

    • Michelle McDonald says:

      I wish to say thank you to all that have responded to this article. I am a Continuing Care Assistant from Nova Scotia who has been looking at eventually moving to Ontario. By doing so, I have been researching health care in long term facilities in Ontario. I will admit that I too have seen some instances of neglect in my current position, but I must say from what I have read, I am rather nervous as to the situation I am looking at. In Nova Scotia the ratios are much more manageable, usually 1 staff member to 6 or 9 residents and even then depending on what the day provides you, you are still scrambling to complete some tasks.

      With my course, I am only to assume that it is similar to that which is taught in Ontario, we are enforces DIPPS – Dignity, Independence, Preference, Privacy, and Safety. Personally, I believe that you can improve a residents quality of life exponentially just by fallowing those simple principles while completing your tasks. It is true that there will be times which there is simply no time to spend additional time with each person, but while you are completing your tasks, you can do so much more to put a smile on so many faces.

      I must say in regards to Catherine Richards, you remind me of my instructor. Your passion and knowledge is overwhelming that I was quite surprised you do not work in the field. I hope that when I finally do make the move, hopefully there will be staff members who have as much passion and compassion as you and the many other people who have taken the time to respond.

      Michelle McDonald

      • Catherine Richards says:

        Hi Michelle:

        Thank you for adding your own thoughtful comments to the discussion. Your voice of experience and your desire to make a positive difference in the healthcare field is not only admirable, it is needed. If more people working in caregiving capacities were to adopt your attitude and put into daily practice the wonderful carer philosophy you so well describe, I believe that a lot more good would be achieved and a lot less harm done, and all for the benefit of vulnerable people of all ages, but especially the defenseless, frail elderly and disabled whom are dependent upon quality care.

        I hope you and others will check out my Facebook group and join us as we try to raise awareness of the issues in long term care homes and hospitals, home-care and retirement homes in Ontario. We are hoping that one day soon the government will increase the mandate of the Ontario Ombudsman to empower him with independent oversight of the healthcare system.

        Thank you again for your support and encouragement. Where ever you choose to work, you will be an asset to those you serve. We need more people like you in healthcare to join the many other good people in the caregiving professions who, like you, want to make a difference and are willing to speak up for those whose voices are not always heard.

        PS I spent eight years of my childhood in Nova Scotia, the birthplace of my late Mom, Martha.

        Catherine Richards,
        Cause for Concern: Ontario’s Long Term Care Homes
        “Advocates for Just Healthcare”

      • Barb Bursey says:

        Hello, I have read thru your 2 positions/articles written and wish that you worked in LTC. I am a nurse in a large one in Ontario where the HCA/PSW each have 12 to 13 residents each. If you put in another person who does not work in LTC to handle all the problems, you are asking for more trouble. At present we have the Ministry of LTC coming in every other month to inspect this or that. Who cares if the water jug that has ice in it, sits on a tray of ice to keep it cold. Who cares if a Res. sits infront of the tv for a good part of the day, but is uncommunicative , staff do move this person’s position as per LTC act. The people that run this ministry have NO idea what the front line staff have to deal with every day. Every one says to protect the residents, what about the staff that get hit, slapped, spit on, kicked on a daily basis and are told that they have to deal with this as it is part of their job. Do you think they would allow this in a hospital – no they use restraints. I know that is not the answer but everyone needs to quit blaming the staff – there is not appreciation for the front line staff at all in an nursing home. Families can complain and a staff member can be fired on the spot, and the union may or may not be able to get their job back. We had one staff member get fired as she slapped a Res. who bit her finger on purpose as she was cleaning his teeth. He cut her finger. It is an automatic reaction to slap or stop someone from hurting you, I believe she did this for protection. I am all for protecting the Res. from any type of abuse but am getting sick of hearing about staff getting abused and no one cares. Look at the increase in stats for WSIB claims from nursing homes. I know of 10 staff here alone that are on permanent disability from being hurt here and 8 of the 10 are below the age of 35. As for the Dr. above leaving LTC due to abuse, where did he work, what happened to the zero tolerance for abuse. I am on the JOHSC at my facility and can see the staff that have been affected by abuse as well.

  • nursing home doctor says:

    I used to be a nursing home doctor in a few different nursing homes. The neglect and abuse at the first home made me switch to the next. I quickly realized these issues are systemic and increasing staffing ratios won’t do anything.

    I would sooner die young than be placed in an Ontario nursing home. If I do live to be older and lose my independence I hope my children will take me in.


Karen Born


Karen is a PhD candidate at the University of Toronto and is currently on maternity leave from her role as a researcher/writer with

Irfan Dhalla


Irfan is a Staff Physician in the of Department of Medicine at St. Michael’s Hospital and Vice President, Physician Quality and Director, Care Experience Institute at Unity Health Toronto. Irfan also continues to practice general internal medicine at St. Michael’s Hospital.

Republish this article

Republish this article on your website under the creative commons licence.

Learn more