Carleton Lodge (55 Lodge Road, Nepean) is a non-profit nursing home, that is owned and operated by the City of Ottawa. There are approximately 160 beds.
Inspection Reports for Carleton Lodge
Our research team carefully reviewed and summarized inspection reports for Carleton Lodge. You can read the original copies of the reports in the Government of Ontario website.
November 2023
The inspection, conducted between October 3 and October 18, 2023, was a Proactive Compliance Inspection.
- Plan of Care: The inspection identified that the licensee, City of Ottawa, failed to ensure that the care specified in the resident’s plan of care was properly documented. Specifically, there were instances where scheduled care, such as baths and nail care, was not documented for residents. This lapse in documentation raises concerns about the consistency and adequacy of care delivery.
- Minister’s Directive: The inspection revealed that the licensee did not ensure staff followed the Minister’s Directive related to COVID-19 Response Measures for Long-Term Care Homes, effective August 2022. Specifically, staff did not consistently wear appropriate personal protective equipment, including eye protection, when working in areas with suspected or confirmed COVID-19 cases. This non-compliance increases the risk of disease transmission among residents and staff.
- Skin and Wound Care Program: The licensee failed to meet the requirement of evaluating and updating the skin and wound care program and relevant policies annually, as mandated by regulations. This lapse in annual review may result in outdated practices that could impact the quality of care provided to residents, especially those with skin and wound care needs.
- Pain Assessment Program: The inspection revealed that the pain management program and relevant policies were not updated annually, as required by regulations. The last revision of the pain assessment policy was noted to be in September 2019. This lack of regular updates may hinder the effectiveness of pain management for residents.
- Nutritional Care and Hydration: The inspection found that food and fluid intake for residents identified as being at nutritional risk were not consistently documented. There were instances where nourishment intake for specific meals was not documented over multiple days. Failing to document food and fluid intake for residents at nutritional risk can impact the monitoring of their nutrition and hydration needs.
- Infection Prevention and Control: Staff members were observed not following proper hand hygiene practices after removing gloves. This lapse in infection prevention and control measures, especially in areas with COVID-19 outbreaks, increases the risk of disease transmission among residents and staff.
August 2023
The report is based on an inspection carried out between August 14 and August 21, 2023. The inspection was conducted in response to complaints and critical incidents.
- Plan of Care Reassessment: The licensee failed to ensure that the plan of care was reviewed and revised when the care set out in the plan was no longer necessary. The resident’s plan of care specified constant supervision but was not updated when the resident became capable of staying in their room unattended with appropriate alarms.
- Dental Care Compliance: The licensee did not ensure that dental care, as specified in the plan of care, was provided as required. Dental care was provided only twice a day, as per the resident’s preference, instead of after each meal as specified in the plan.
- Assistance with Transfers, Dressing, and Ambulation: The licensee did not ensure that the care set out in the plan of care regarding assistance with transfers, dressing, and ambulation was provided as specified. Video footage showed the resident self-transferring and ambulating independently, contrary to the plan of care, which required staff assistance.
- Device Use: The licensee failed to ensure that the resident’s device was used as specified in the plan of care. The device was not attached to the resident’s clothing as required, and it was found hanging to the side of the wheelchair.
June 2023
The report is based on an inspection carried out between June 20 and June 22, 2023, under the Critical Incident System.
Carleton Lodge initially failed to ensure that a resident’s plan of care was reviewed and revised when the resident’s care needs changed after sustaining an injury. This non-compliance was reported as a critical incident. However, the licensee remedied this issue by updating the resident’s plan of care, including appropriate interventions related to the injury, before the conclusion of the inspection. The inspector was satisfied that the non-compliance had been addressed and required no further action.
April 2023
The inspection, led by Karen Buness and assisted by Ashley Martin, was a response to specific complaints and incidents and occurred on several dates between March 30 and April 12, 2023.
The most significant non-compliance issue was related to the Plan of Care. This non-compliance was related to a resident who experienced an unwitnessed fall. It was found that the bed alarm, which was part of the resident’s individualized fall prevention strategy, was not functioning at the time of the incident. This was confirmed through both the resident’s electronic health record and interviews with registered staff. The resident’s Care Plan had clearly indicated a risk for falls and included prevention strategies like the use of a bed alarm. The failure to ensure the functioning of the bed alarm put the resident at a higher risk for falls.
September 2022
This inspection, led by Cheryl Leach with support from Andy Natarajan and Erica McFadyen, occurred over several days in August and September 2022. It was in response to critical incidents and complaints.
The inspection addressed multiple issues, including concerns about staffing, neglect, resident care (especially continence, bathing, dining, and snack service), several falls resulting in hospital transfers and significant changes in resident condition, a choking incident, and staff-to-resident and resident-to-resident altercations.
The inspection protocols included Falls Prevention and Management, Food, Nutrition and Hydration, Infection Prevention and Control (IPAC), Prevention of Abuse and Neglect, Resident Care and Support Services, Responsive Behaviours, and ensuring a Safe and Secure Home.
- Failure in Care Plan Compliance: A resident received the wrong diet texture, leading to a choking incident. This was a violation as the staff failed to follow the specified care plan.
- Inadequate Assessment Integration: Post-fall, a resident’s assessments were not adequately integrated and collaborated upon by the care team, leading to potential risks of delayed treatment and negative health outcomes.
- Air Temperature Monitoring Failure: For several days, the licensee failed to measure and document the air temperature in resident common areas and designated cooling areas during specified afternoon hours. This oversight posed potential risks to resident comfort and safety.
June 2022
The inspection, led by inspector Mark McGill, was carried out over several days in May 2022. It was primarily focused on a critical incident involving staff-to-resident physical abuse.
The inspection was centered on a critical incident logged as 021062-21 (CIS: M508-000027-21), which related to an instance of physical abuse from staff to a resident.
The inspection used protocols related to Infection Prevention and Control (IPAC) and the Prevention of Abuse and Neglect.
- Failure to Protect Residents: It was found that a Personal Support Worker (PSW) and a Registered Practical Nurse (RPN) failed to protect a resident from abuse. The RPN slapped the resident during care, causing injury. This incident highlighted a breach of the duty to protect residents from abuse at all times.
- Delayed Reporting of Abuse: There was a failure in immediately reporting the incident of abuse to the Director. The charge nurse, instead of reporting directly, asked the PSW to contact the on-call manager by email, leading to a delay in reporting the abuse to the Ministry of Long-Term Care.
August 2021
The inspection, conducted from August 3 to 9, 2021, was led by Janet McParland.
The major non-compliance issue identified was the failure to measure and document air temperature in specified areas of the home. This non-compliance included not measuring temperatures in at least two resident bedrooms, one common area on every floor, and every designated cooling area at required times. It was noted that from May 15, 2021, to June 6, 2021, the home failed to document these temperatures. This oversight posed risks to resident comfort and safety.
April 2021
Inspectors Lisa Cummings and Linda Harkins from the Ottawa Service Area Office led this inspection between March 3-18, 2021.
The primary non-compliance issue identified was concerning the protection from certain restraining. Specifically, a resident was improperly restrained by physical barriers preventing them from leaving their room. This was observed during the inspection, where a barrier was placed at the doorway of the resident’s room, indicating a failure to adhere to proper regulations regarding resident restraint.
February 2020
This report covers a critical incident system inspection. The inspection, led by Janet McParland, was carried out on February 19-24, 2020.
The licensee failed to comply regarding falls prevention and management. Specifically, after a resident had fallen, proper post-fall assessments using a clinically appropriate assessment instrument specifically designed for falls were not conducted. This was evidenced in the case of a resident who unexpectedly passed away (Resident #001), who had been identified as at risk for falls. Despite experiencing multiple falls, no post-fall assessment tools were completed for each incident.