TORONTO — A series of Ontario Ministry of Health inspection reports conducted at the Apotex Centre, Jewish Home for the Aged, more commonly known as Baycrest, found instances of physical abuse of residents, wheelchairs and sling lifts tainted with feces, unlocked medication carts and various other violations of health standards.

Responding to the reports, William Reichman, president and CEO of Baycrest, said they reflect isolated incidents that have been addressed and that do not detract from the centre’s overall high standards and aggregate top performance as a long term care (LTC) facility.

The ministry reports date from August and October 2014, as well as February 2015. The most recent inspection report is also the most extensive. Issued on Feb. 4, it came after 15 days of inspections by three ministry employees. It reported that on multiple occasions, Baycrest failed to comply with Ontario’s Long Term Care Homes Act (LTCHA).

In one case, “resident No. 23” was repeatedly abused by their spouse.

The inspectors also found “two other residents who were not protected from abuse by a staff member,” and the report referred to a previous compliance order dated Aug. 25, 2014, meant to prevent further abuse.

The Aug. 25 report found several instances of physical abuse by a Baycrest employee, which were witnessed by a colleague. The report states that “staff member A” physically abused a resident “by pulling his/her arms behind his/her back in a restraining manner and forcing the resident to walk to his/her bedroom without the resident’s consent.”

Inspectors were told that staff member A on other occasions abused a resident during care by getting on the resident’s bed and placing “his/her knee on the resident’s hand to prevent the resident from punching him/her.”

That same staffer put their knee on another resident’s leg “in a forceful manner to prevent him/her from kicking him/her.”

The resident was afraid of staff member A, and when the resident “became tense and resisted care, staff member A aggressively shoved the resident to sit forward in the wheelchair when the resident was leaning back in the chair,” the report stated.

A different Baycrest employee, identified as “staff member D,” also reportedly abused a resident. A third staff member reported concerns to the charge nurse but “nothing had been done about his/her concerns,” the inspectors reported.

The inspectors issued a compliance order in August requiring Baycrest to implement a plan to protect its residents from abuse, develop a process to monitor and evaluate the care it provides and ensure that all staff are re-trained in the home’s policy of zero tolerance of abuse of residents.

The inspectors noted that Baycrest had been in non-compliance of previous orders to report abuse following inspections in May 2014 and November 2011.

In the February report, inspectors ordered Baycrest to prepare protocols to ensure residents are protected from abuse.

The August 2014 report included a finding by inspectors that wheelchairs were soiled with feces, and a body sling was also soiled with human waste. It reported that an incontinent resident was found with fecal matter on their body.

Reichman acknowledged that on occasion, Baycrest failed to live up the standards it has set for itself.

“These particular events I believe are isolated episodes. That doesn’t make them unconcerning, because we dropped the ball in these episodes. But we don’t have evidence to suggest they are emblematic of systematic problems at Baycrest,” he said.

William Reichman

Reichman said the staff member identified as abusing a resident was let go, as was another staffer who witnessed the incidents, but failed to report it.

“Any time we fail to meet our standards for excellence, we’re disappointed in ourselves,” he said. “That is a consistent belief system here at Baycrest. Improving and achieving the standards of excellence that the community is entitled to and expects is what drives us. We take these things incredibly seriously. Individual episodes such as those that get documented by compliance reports, by survey visits, by our own collection of data, we put all this together into an aggregated picture of how we are performing as an organization. So we need to be careful when isolated incidents are identified. We need to be careful why they happened, what we can do to prevent them from happening again, and to what extent they might be representative of larger systems issues.

“When you evaluate an organization’s performance like Baycrest, you have to look for information from a whole variety of sources. This particular source is important, but it should never be viewed as the sole source.”

Reichman pointed to the Senior Quality Leap Initiative, a consortium of 12 high-performing organizations in Canada and the United States that co-operate to improve quality of care for residents.

A 2013 report he provided looked at care outcomes among seven nursing home members. Baycrest was rated second overall in composite score, which looked at elements including mood worsening, pain worsening, proportion of residents who are physically restrained and changes in behaviour.

Reichman said these reports are “the gold standard for how you measure quality in long term care.”

There have been shortcomings in performance by individual staff members, he acknowledged, but “that should not be taken as representative of how all staff members perform their jobs. That’s as true for Baycrest as for any organization that relies on people.

“We’re not perfect. No other organization in health care or probably in any other human endeavour is perfect.

“When something like these events happens… we evaluate why this happened and we take the necessary steps, as we did with the staff member who was a little too physical.”

According to Ministry of Health spokesperson David Jensen, the February inspection report found that Baycrest had at that time not yet complied with the ministry’s order of August 2014, “and a new compliance order was issued.”

“The non-compliance in this case relates to specific residents who were not protected from abuse by a staff member employed by the LTC home,” he added.

Responding to that allegation, Reichman said, “If the ministry has arrived at the conclusion that we’ve been non-compliant with a previous order and we determine that they’re correct in that, then we try to best understand why. So what did we miss, what did they ask us to do that we didn’t do, and how are we going to make sure that next time this doesn’t arise as an issue. And we train our staff, we make sure they fully understand what the compliance orders are, what the rules are and we equip them to be successful.”

“I wouldn’t draw the conclusion that we ignore ministry compliance orders and that this is systematic. This is one episode.

“We’ve done a lot of staff training since,” he added.

Addressing the issues of cleanliness, Reichman said, “The cleanliness issues were largely ascribed to one staff person, where there were performance issues.”

Baycrest is not the only LTC facility to run afoul of statutory requirements. The ministry’s inspection program under the LTCHA looks at the facilities and responds to specific complaints. It conducts inspections in 629 LTC homes.

A random sampling from the ministry’s website revealed that an inspection of another Toronto seniors home, managed by one of North America’s leading providers of seniors accommodation, found issues of cleanliness, though mostly of grime and food splatters, in a January inspection.

A July 2013 report found an instance of a  resident complaining that they had been “handled roughly” and hit on the back and that the home’s written policy on abuse did not identify programs of training and retraining on the issue.

A September 2012 inspection of another home in Toronto found a resident claimed they had been slapped when they refused treatment.

Other inspections focus on issues such as a written plan of care for each resident, bathing protocols, steps for treating pressure ulcers, safety issues and resident-staff communication systems in place.

Reichman said Baycrest is equipped to readjust its procedures when shortcomings are brought to its attention.

“What’s important is that we have a climate here at Baycrest that if we make a mistake, we know we made a mistake, we investigate thoroughly why we’ve made the mistake, and then we take appropriate action to minimize the risk of the mistake occurring again.

“I am very comfortable, if you look at all the sources of information that talk to us about how Baycrest is doing, that Baycrest is an exceptional organization. But you need to look at all of the data, not just the outlier events that are reported to the ministry under the legislative framework.”