Management of Summerland Seniors Village is changing the way it keeps track of residents and their care in the wake of two deaths this year.
In response to the death of Alfred Bonaldi, 91, who missed meals for three days in late November while staff failed to check on him, the facility has new procedure for reporting absences and following up.
Changes in staff training, reporting and supervision are being made in response to the death of Mr. Bonaldi’s wife, Maria Luisa, 84, who died in August after she fell during bath care.
The incident went unreported. She was diagnosed with a broken leg a week later and underwent surgery. She died shortly after that.
The company that owns Summerland Seniors Village outlines the changes in a letter dated Dec. 19 to residents and families.
The letter is signed by Tony Baena, vice-president of operations for Retirement Concepts.
The letter expresses condolences to the family of Mr. Bonaldi, who died Dec. 7.
Baena said that he and Azim Jamal, president and CEO of Retirement Concepts, met a couple of weeks ago with Pat McCoy, one of Mr. and Mrs. Bonaldi’s daughters, to discuss the incidents involving her mother and father at Summerland Seniors Village.
“Azim and I took the opportunity to sincerely apologize to Pat and her family for all they have gone through over the past several weeks and months. Pat did make us aware of information that was previously unknown to us including errors in reporting the injury to Mrs. Bonaldi. Thanks to the information Pat provided to us we will be taking appropriate action to improve our policies, procedures, reporting and communication.”
The letter says that in Mr. Bonaldi’s case, there was a breakdown in communication that resulted in his absence from meals not being investigated for several days before he was found in his room.
“In this case too, we are taking steps to improve our follow-up procedures and communication between staff members,” said Baena.
“Unfortunately, even the best policies and procedures cannot eliminate human error. Nevertheless, we will continue to strive to improve our systems and staff training so that we can reduce human error to an absolute minimum.”
Baena said the Summerland Seniors Village leadership team has developed an action plan to address the priorities identified in a recent quality audit and licensing inspection completed by Interior Health.
Interior Health has assigned a clinical consultant to work alongside the leadership team at Summerland Seniors Village.
This is how the company is changing policies and procedures about meal times for the Independent and Assisted Living Building:
• When a resident is not present at a meal the dining staff is required to fill out a form indicating that the resident is absent.
• This form is then given to the home support worker who is required to follow up with a check on the resident¹s whereabouts.
• If the home support worker cannot find the resident further steps are taken to report the resident¹s absence to other staff and/or family.
Baena says the facility is also making the following changes to improve service in residential care:
• Additional guidance to staff on the use of bath chairs, lifts and transfers and the use of safety belts and brakes in the tub chairs.
• Delivered comprehensive in-service training to all Care Aides and Licensed Practical Nurses on the appropriate use of seat belt restraints.
• The implementation of pain assessment tools.
• An improved policy and training on the use of restraints.
• Education on the 24- hour report form to promote the exchange of information between shifts and departments.
• Daily rounds by the Director of Care and the Assistant Director of Care to assist LPNs with decision making.
The following steps are also planned:
• Education for the LPNs to enhance their skill for head to toe assessments as it relates to seniors.
• Education on incident reporting, follow-up, and enhancement of our policy on incident reporting.
• Implementation of the Resident day/Family story.
The facility is being investigated by an inspector from the Ministry of Health, and the death of Mr. Bonaldi is being investigated by the B.C. Coroner Service.