Nisbet Lodge

Nisbet Lodge (740 Pape Avenue, Toronto) is operated by Nisbet Lodge Foundation. The facility has a capacity of approximately 103 beds.

In this article, our Good Caring Canada team has reviewed Nisbet Lodge 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 Nisbet Lodge.

Table of Contents:

• Inspection Reports for Nisbet Lodge
• Performance Indicators for Nisbet Lodge
• Resident Profile of Nisbet Lodge

Inspection Reports for Nisbet Lodge

Nisbet Lodge 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 Nisbet Lodge. Original copies of the inspection reports can be read in the Government of Ontario website.

🔍  January 2024

The inspection for Nisbet Lodge addressed several main intakes involving non-compliance with care plans, directives by the Minister, general program requirements, skin and wound care, infection prevention and control, and critical incident reporting.

• Plan of Care: The licensee did not ensure that a resident’s plan of care was followed. The resident, at risk for falls, was supposed to wear a specific device for injury prevention. Staff did not provide or encourage the resident to use the device, and the DOC confirmed this oversight. This failure increased the risk of injury for the resident in the event of a fall.

• Directives by Minister: The licensee failed to carry out infection prevention and control (IPAC) audits as required. During COVID-19 outbreaks, weekly IPAC audits were not completed, which could lead to undetected gaps in infection control measures. Additionally, staff did not follow masking requirements during meal service, increasing the risk of respiratory infection transmission.

• General Requirements for Programs: The licensee did not keep a proper written record of the annual evaluation of the skin and wound program. The record lacked essential details such as the date of the evaluation, participants’ names, changes made, and implementation dates. The CEO acknowledged this deficiency.

• Skin and Wound Care: The licensee failed to ensure that a resident received an assessment for altered skin integrity. The registered staff did not complete the necessary assessment, and the DOC confirmed this failure, which increased the risk of improper management of the resident’s condition.

• Infection Prevention and Control Program: The licensee did not implement the IPAC program according to standards. Residents were not assisted with hand hygiene before meals, and the IPAC lead did not work the required 26.25 hours per week on-site. These failures posed risks of infection transmission and ineffective IPAC management.

• Reports re Critical Incidents: The licensee failed to inform the Director immediately of an outbreak of a disease of public health significance. The home experienced multiple outbreaks, and the initial outbreak was not reported until four days later. This delay in reporting could impact the timely management of the outbreak.

🔍  December 2023: Inspection

The inspection for Nisbet Lodge addressed multiple non-compliance issues, some of which were remedied during the inspection.

Non-Compliance Remedied:

• Plan of Care: The licensee failed to ensure that the care set out in the plan of care was provided to a resident as specified. The resident, at risk for falls, required a device to assist with fall prevention. A PSW found that the device was not functioning and had not been provided to the resident. The DOC acknowledged the issue, and the device was fixed before the inspection concluded. The risk to the resident was low as the device was meant to reduce falls risk. The remedy was implemented on November 30, 2023.

• Security of Drug Supply: The licensee failed to keep the medication storage areas locked at all times. On November 30, 2023, the seventh-floor medication room was found propped open with no staff present for approximately 10 minutes. The RPN who locked the door afterward acknowledged the mistake. The DOC confirmed that the medication room should always be locked. The risk was low, as the safety of the drug supply could not be ensured during that period. The remedy was implemented on November 30, 2023.

Unresolved Non-Compliance:

• Plan of Care: The licensee did not ensure that a resident received wound care as specified in their plan of care. The resident, diagnosed with a wound, did not receive the necessary intervention. The RPN could not provide documentation confirming the wound was healed, and the wound required further treatment. The DOC acknowledged the failure, which put the resident at risk of infection.

• Nutritional Care and Hydration Programs: The licensee failed to comply with the weight monitoring system. A resident’s weight was not rechecked after a significant decrease, as required by the home’s policy. The RPN, RD, and DOC acknowledged the oversight, which put the resident’s nutritional status at risk.

• Skin and Wound Care: The licensee failed to ensure that strategies to prevent infection and monitor skin integrity were in place. Staff did not observe a resident’s skin condition as required, leading to the deterioration of a wound. The DOC confirmed the responsibility of PSWs to observe and report skin impairments.

🔍  July 2023: Inspection

The inspection for Nisbet Lodge addressed several non-compliance issues, with some being remedied during the inspection.

Non-Compliance Remedied:

• Privacy During Personal Care: The licensee failed to ensure resident #005 was afforded privacy during personal care. Staff left the door open while assisting the resident with toileting, exposing them to view from the hallway. PSW #110 and Nursing Lead #105 acknowledged the breach of privacy. After the inspector’s intervention, the door was closed, and care was completed in private. This remedy was implemented on June 27, 2023.

Unresolved Non-Compliance:

• Written Plan of Care: The licensee failed to ensure clear directions in the resident’s plan of care for assistance during meals. PSW #101 left the resident unattended, contradicting the care plan, risking the resident’s nutritional health.

• Revising Care Plans: The licensee did not update the care plan following a resident’s fall, missing the implementation of a new intervention. RCM #114 acknowledged the oversight, increasing the risk to the resident due to uncommunicated care needs.

• Collaborative Care: Staff failed to collaborate in the resident’s care assessment, leading to a delay in addressing the resident’s pain and injury. RPN #108 did not communicate the resident’s condition to the evening shift, risking further harm to the resident.

• Intervention Implementation: The licensee did not apply a specified fall prevention device for a resident as outlined in their care plan. PSW #110 acknowledged the lapse, increasing the resident’s fall risk.

• Access to Care Plans: The care plan was missing from the PSW binder, leaving staff without updated care information. Nursing Lead #105 acknowledged the issue, highlighting the risk of uninformed care.

• Duty to Protect: The licensee failed to protect a resident from neglect by RPN #102, who did not assist a resident found in an unsafe position. This neglect was acknowledged by RPN #102 and increased the risk of injury to the resident.

• Investigating Alleged Abuse: The licensee did not immediately investigate an alleged abuse incident reported by a resident. IPAC Lead #100 and DOC #113 confirmed the delay, which could have exposed the resident to further harm.

• Reporting Improper Care: The licensee failed to immediately report alleged improper care of resident #004 to the Director. Nursing Lead #105 noted the delay, which was discovered only after a subsequent complaint.

• Transferring and Positioning Techniques: The licensee did not ensure safe transferring techniques for residents #005 and #006. Both residents were transferred improperly, leading to pain and injury. DOC #113 confirmed the failures, which posed a significant risk to the residents.

• Dining and Snack Service: The licensee did not provide sufficient time for resident #004 to eat at their own pace. PSW #111 rushed the feeding process, confirmed by Nursing Lead #105, increasing the risk to the resident’s nutritional status.

🔍  January 2023: Inspection

The inspection for Nisbet Lodge addressed several non-compliance issues related to residents’ care plans, skin and wound care, training, and infection prevention.

• Plan of Care: The licensee failed to ensure that the care set out in the plan of care was provided as specified for residents #001 and #002. Resident #001 did not have a falls prevention device installed as required, possibly contributing to their fall and injury. For Resident #002, prescribed treatments for altered skin integrity were not followed, leading to worsening conditions. Additionally, Resident #002 was not turned and repositioned every 2 hours as required, increasing the risk of skin impairments.

• Skin and Wound Care: The licensee did not ensure that residents exhibiting altered skin integrity received proper assessments. Resident #002 did not receive weekly skin assessments using the home’s Wound Assessment Tool, nor was a head-to-toe assessment completed within 24 hours of admission, which may have contributed to the failure to identify changes in skin integrity and timely interventions.

• Training: Staff, including agency nurses, were not trained in the home’s Falls Prevention and Management policies. RPN #129 did not use the post-fall assessment forms, leading to inadequate evaluation and intervention after a resident’s fall, increasing the risk of further falls and injuries.

• Infection Prevention and Control (IPAC): The licensee failed to complete the COVID-19 Self-Assessment Audit Tool as required by the Minister’s Directive. This oversight increased the risk of unaddressed gaps in IPAC practices, potentially compromising residents’ health and safety.

• Plan of Care: The licensee did not ensure that Resident #002’s substitute decision-maker (POA) was given the opportunity to participate in the resident’s care. The POA’s request to call the physician due to worsening skin impairment was ignored, leading to increased health risks for the resident.

• Falls Prevention and Management: The licensee failed to ensure a proper post-fall assessment for Resident #001. RPN #129 did not use the required assessment forms, preventing the evaluation of fall prevention strategies and interventions. The staff’s failure to use the post-fall assessment forms as required by the home’s falls policy resulted in the inability to review current interventions.

Performance Indicators for Nisbet Lodge

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 Nisbet Lodge 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 Nisbet Lodge

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.