Fudger House (439 Sherbourne Street, Toronto) is owned and operated by the City of Toronto. There are approximately 250 beds.
In this article, our Good Caring Canada team has reviewed Fudger House from three essential angles: inspection reports, performance indicators, and resident profiles. You are encouraged to thoroughly review all three angles so you can be more informed about the quality and safety of Fudger House.
Table of Contents:
- Inspection Reports for Fudger House
- Performance Indicators for Fudger House
- Resident Profile of Fudger House
Inspection Reports for Fudger House
Fudger House is regulated by the Ontario Ministry of Health and Long-Term Care. The Ministry conducts inspections of all long-term care facilities to ensure that operations are in compliance with provincial regulations, and that residents receive proper care.
Our Good Caring Canada team has summarized inspection reports for Fudger House. Original copies of the inspection reports can be read in the Government of Ontario website.
🔍 December 2023
This comprehensive inspection, led by Oraldeen Brown along with other inspectors, took place over several days at the end of November and early December 2023.
The inspection focused on several critical incidents, including a missing resident, follow-up on compliance orders related to transferring and positioning techniques, and a respiratory outbreak.
- Plan of Care: The inspection revealed a significant lapse in the assessment of resident #001’s safety risks. Despite having a history of elopement, this critical information was not reflected in their written care plan. This oversight was evident when the resident, attending an outdoor program, did not return to the secure area, prompting a Code Yellow. Interviews with staff, including the Programs and Services Manager (PSM #102) and Nurse Manager (NM #104), confirmed their unawareness of the resident’s elopement risk, which was not documented in the resident’s care plan.
- Safe and Secure Home: Fudger House failed to provide a safe and secure environment for resident #001 The incident where the resident was able to leave the property through an open courtyard gate, later found and returned by police, highlighted this failure. The open gate was attributed to contractors working at the site. This incident posed a moderate risk to the resident’s safety and well-being.
🔍 September 2023
This inspection, led by Inspector Oraldeen Brown and Trudy Rojas-Silva, took place over several days in late August 2023.
The focus of this inspection was on critical incidents and followed a structured and comprehensive approach, adhering to various inspection protocols such as Resident Care and Support Services, Continence Care, Infection Prevention and Control, and Falls Prevention and Management.
- Plan of Care: The inspection identified a failure in collaborative care for resident #003. Post-fall, an Occupational Therapist recommended a fall intervention which was not implemented. This failure in collaborative implementation of the intervention put the resident at risk of further injury. There was also a lapse in the care provided to resident #003, specifically regarding incontinence care. The care plan’s frequency was not followed, increasing the risk of potential skin breakdown for the resident.
- Compliance Order on Transferring and Positioning Techniques: The inspection revealed non-compliance in using safe transferring and positioning devices or techniques. A particular incident involved PSW #103 improperly transferring resident #001 using a mechanical device, resulting in significant injury.
🔍 February 2023
The inspection, led by Kim Lee, focused on a series of intakes related to falls and infection prevention and control measures.
This comprehensive inspection, spanning several days in early February, adopted specific protocols for Infection Prevention and Control, ensuring a Safe and Secure Home environment, and Falls Prevention and Management.
- Infection Prevention and Control Program: The inspection identified a lapse in the implementation of the Infection Prevention and Control (IPAC) program. Specifically, it was noted that a visitor entered Fudger House without undergoing COVID screening, a violation of the home’s policy and general health guidelines. Despite Fudger House not being in an outbreak at the time, this oversight in screening practices posed a moderate risk for potential COVID exposure among residents.
🔍 September 2022
This inspection was led by Stephanie Luciani, alongside Inspector Ramesh Purushothaman, and covered a range of critical incidents, primarily centered on falls prevention and management, along with inspections related to a safe and secure home environment.
- Reporting and Complaints: The inspection found non-compliance regarding the immediate notification of the Director when a resident was missing from the home for more than three hours. In a specific incident in February 2022, a resident who informed the staff of their temporary absence did not return as expected, leading to a delay in notifying the Director.
- Infection Prevention and Control Program: The inspection identified a failure in adhering to hand hygiene protocols. A staff member was observed assisting residents without performing necessary hand hygiene, contravening the home’s policy and increasing the risk of infection transmission.
🔍 August 2021
Inspector Nazila Afghani led the first of two inspections, with the objective to evaluate and address several critical incidents related to fall prevention and medication administration.
In the first inspection, Fudger House was found non-compliant with the Long-Term Care Homes Act, 2007, which mandates that the care detailed in a resident’s plan must be accurately provided. It was observed that necessary equipment, critical for managing a resident’s risk of falls, was not functioning due to a battery issue and connectivity problems, as confirmed by RN #111 and PSW #117.
In another inspection, Non-Compliances were not issued.
🔍 November 2020
Inspectors Praveena Sittampalam and Matthew Chiu led this inspection. The main focus of this inspection was on a critical incident report related to an infection outbreak and several issues pertaining to resident care and safety.
- Infection Outbreak: The inspection included a review of Log 020861-20, which was a Critical Incident System (CIS) report (M524-000018-20) related to an infection outbreak at Fudger House. Effective management of such outbreaks is crucial in long-term care settings to protect the health and well-being of residents.
- Resident Privacy: There was a non-compliance issue regarding resident privacy. It was observed that privacy dividers were not adequately used, and some residents were visible to others while receiving care. This observation indicates a need for better implementation of privacy measures for residents during their treatment and personal care.
- Safe and Secure Environment: The inspectors noted that Fudger House failed to provide a safe and secure environment for its residents. Specific observations included a lack of monitoring systems for residents in the auditorium, potential hazards from a cluttered stage area with loose wires, and insufficient monitoring of resident movements.
- Communication and Response System: There was a failure in ensuring that a resident-staff communication and response system was available at each resident bed in the auditorium. This lack of communication access could hinder timely assistance for residents.
- Infection Prevention and Control Program: The inspection highlighted shortcomings in the implementation of the infection prevention and control program. This included improper use of personal protective equipment (PPE), insufficient hand hygiene practices, and failure to maintain appropriate distancing between residents.
🔍 July 2020
During the course of this inspection, Non-Compliances were not issued.
🔍 January 2020
The inspection was led by Gordana Krstevska. This inspection focused on various critical incidents including falls, a missing resident, and allegations of abuse.
The inspection reviewed incidents related to falls, a missing resident, and abuse.
- Plan of Care: Fudger House failed to ensure that the plan of care was based on an interdisciplinary assessment concerning the resident’s health conditions, including risk of falls.
- Pain Management: There was a failure to assess a resident’s pain using a clinically appropriate assessment instrument when initial interventions did not relieve the pain.
Performance Indicators for Fudger House
Our research team at Good Caring Canada has compiled data on seven key performance indicators for long-term care facilities in Ontario.
We invite you to review each of the below indicators — to compare Fudger House with other long-term care facilities in Ontario.
- 💊 Potential misuse of antipsychotics is measured by the percentage of residents taking antipsychotic drugs, without a diagnosis of psychosis
- 🔒 Potential excessive use of physical restraints is measured by the percentage of residents in daily physical restraints
- 🤕 Fall risk is measured by the percentage of residents who fell in the 30 days leading up to the date of their quarterly clinical assessment
- 🦽 Worsened physical functioning is measured by the percentage of residents who worsened or remained dependent in transferring and locomotion (mid-loss ADLs), less residents who improved or remained independent
- 🩹 Worsened pressure ulcers is measured by the percentage of residents whose stage 2 to 4 pressure ulcer worsened since the previous assessment
- 😣 Pain is measured by the percentage of residents who report to have moderate daily pain or horrible/excruciating pain at any frequency
- ☹️ Worsened depressive mood is measured by the percentage of residents whose mood from symptoms of depression worsened
Resident Profile of Fudger House
Understanding the resident profile of a long-term care facility can help you assess the facility’s appropriateness and compatibility for a patient. Our research team at Good Caring Canada compiled data on three main elements to understand resident profiles. We invite you to review each of the three below elements.
- 👵🏻 Gender profile can be helpful for assessing the gender compatibility of a long-term care facility.
- 👴🏻 Age profile can be helpful for assessing whether a long-term care facility has experience in caring for residents of specific age groups. More residents of advanced age may imply potential challenges to adequate and equitable care for all residents in the facility.
- 💭 The percentage of residents with dementia can be helpful for assessing whether a long-term care facility is aware and ready for dementia care. A higher percentage may imply more relevant care services. A higher percentage may also imply potential challenges to adequate and equitable care for all residents in the facility.