Long-Term Care Home Public Inquiry Report Recommendations
The government and long-term care sector partners have been comprehensively reviewing the recommendations from the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System and have completed a total of 18 recommendations, with another 40 recommendations underway.
The Public Inquiry recommendations address systemic issues in Ontario's long-term care system. The recommendations are based on four key themes: Prevention, Awareness, Deterrence and Detection.
The completed recommendations, which both the government and sector partners are responsible for implementing are listed below.
Theme 1 - Prevention: Building capacity and excellence in long-term care will improve quality of care, and the safety and security of residents.
The College of Nurses of Ontario has reviewed and improved its policies and procedures to reflect the possibility that a nurse or other healthcare provider might intentionally harm those for whom they provide care.
The Ministry of Long-Term Care is collaborating with the Ministry of Health's Home and Community Care Branch in providing healthcare services to older Ontarians.
Theme 2 - Awareness: By building awareness throughout the healthcare system about possible harm and abuse of the residents and patients we can prevent, deter and detect concerns about the quality of care/safety and security of residents.
The College of Nurses of Ontario has reviewed and improved its intake investigation process, following receipt of termination and other reports, by training intake investigators on various topics such as the serial killer phenomenon, identifying all relevant contacts in an investigation and assessing risk levels.
The College of Nurses of Ontario launched a revised version of their mandatory reporting guide to include easy-to-understand information about what, when and how to report a concern to them.
The College of Nurses of Ontario has revised its mandatory reporting form and process for submitting reports, including clearer instructions and the ability to submit the form electronically.
The Minister of Long-Term Care has issued a policy directive ensuring that a long-term care home's written policy for the destruction and disposal of drugs covers insulin cartridges.
Theme 3 - Deterrence: Utilize a variety of tools and professions to strengthen medication management and deter intentional medication errors.
The Minister of Long-Term Care has issued a policy directive requiring long-term care homes to treat the use of glucagon as a medication incident.
The Long-Term Care Homes Division of the Ministry of Long-Term Care has advised long-term care homes that the use of glucagon constitutes a medication incident.
Theme 4 - Detection: The Commissioner recognized that Ontario has a strong death investigation system with excellent leadership. The government will build on those strengths by tailoring the death investigation process as it applies to deaths in long-term care homes.
Long-term care inspectors ensure that all Critical Incident reports and complaints relating to high-risk incidents are given the highest priority and inspected as quickly as possible to ensure that any ongoing risk to residents is immediately remedied.
When conducting inspections and establishing inspection priorities, the Ministry of Long-Term Care is guided by the Long-Term Care Home Quality Inspection Program Performance Assessments and data produced by the Information Management, Data and Analytics Branch showing homes with higher than expected mortality rates.
The Ministry of Long-Term Care uses the Long-Term Care Home Quality Inspection Program Performance Assessment to identify long-term care homes struggling to provide a safe and secure environment for their residents.
Before beginning an inspection involving either missing narcotics or allegations of staff-to-resident abuse, the Ministry of Long-Term Care ensures that the assigned inspector reviews previous Critical Incident reports to determine whether the staff member involved in those incidents is named in earlier reports.
The Minister of Long-Term Care has issued a policy directive requiring long-term care homes to document and track the use of glucagon to identify patterns and trends, and flag where further investigation should be undertaken.