Fairhaven

Fairhaven (881 Dutton Road, Peterborough) has 256 residents, most of whom need nursing or special care. The facility have one floor designated to the care of people with special needs such as residents with advanced Alzheimer’s or dementia.

Fairhaven is located in Peterborough, which is known as the ‘gateway’ to the Kawarthas or “cottage country”, a large recreational region in Ontario.

Fairhaven moved to its current location in 2003 and has a special care unit where programming is adapted to the functional needs of residents who are physically active
and cognitively impaired.

Fairhaven is jointly owned by the City and County of Peterborough.

According to Peterborough Examiner, the majority of Fairhaven’s funding comes from the Ministry of Long-Term Care, but funding is also provided by the county, which owns one third of the facility, and the city, which owns two thirds.

The Fairhaven Foundation raises money for necessary items like medical lifts, physiotherapy equipment, and improvements to the building.

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November 2023 🚨

The inspection report was completed by April Chan, Tiffany Forde, and Laura Crocker.

• Abuse and Neglect: There were multiple incidents of staff-to-resident abuse, both physical and verbal. In one case, a staff member was observed hitting a resident, causing the resident pain. Another instance involved a Personal Support Worker (PSW) speaking to a resident in an intimidating manner and providing care roughly. The home failed to fully promote a resident’s right to freedom from abuse.
• Failure to Protect Residents: The facility did not adequately protect residents from abuse. There was a reported incident where a resident was physically abused by a staff member. The investigation confirmed the abuse, highlighting a breach in ensuring resident safety.
• Inadequate Response to Incidents: The home was found to be lacking in its immediate investigation of incidents, specifically in cases of resident-to-resident physical abuse. This failure potentially exposed residents to ongoing risks of abuse.
• Ineffective Reporting and Complaints Management: There were failures in reporting incidents to the Director as required. This included delayed reporting of staff-to-resident abuse allegations.
• Falls Prevention and Management: The home did not properly implement its falls prevention program. In one instance, a resident at risk of falls did not receive the specified intervention as frequently as their care plan required, increasing their risk of falling.
• Responsive Behaviours Management: The facility failed to develop and implement written approaches and strategies to prevent, minimize, and respond to residents’ responsive behaviours. This failure increased the risk of staff being unaware of the care needs of residents with such behaviours.
• Infection Prevention and Control: There were lapses in infection control practices, including failure to clean high-touch surfaces more than once daily during an infectious disease outbreak. Additionally, staff were observed not following proper procedures for donning and doffing PPE, which could contribute to the spread of infections.
• Housekeeping and Environmental Issues: The report pointed out that the facility did not assign a housekeeper to an outbreak unit, and high-touch surfaces were not cleaned as frequently as required.
• Staff Hiring Protocols: The facility did not adhere to required protocols for hiring staff, specifically in obtaining necessary police check disclosures from new hires during the pandemic.
• Record Keeping: There were failures in maintaining records of current residents, with certain health records not kept as required.

July 2023 🚨

The inspection was completed by Carole Ma, Sharon Connell, and Patricia Mata.

• Plan of Care Non-Compliance: There were multiple instances where the licensee failed to ensure collaboration with physicians and nurse practitioners in assessing and responding to changes in residents’ conditions. This included a delay in informing healthcare professionals about a resident’s deteriorating appearance and motor skills, and a delay in collecting urine specimens for testing.
• Failure in Fall Prevention and Management: The facility did not ensure the proper functioning of fall prevention equipment, putting residents at risk of falling. Additionally, there was a failure to complete post-fall assessments using clinically appropriate assessment instruments.
• Consent Issues: There was a failure to obtain consent from a substitute decision-maker before administering immediate medication to a resident. This breach potentially exposed the resident to medication misuse and an erosion of their rights.
• Protection from Restraining and Confining: The report found that the facility used a medication as a chemical restraint without meeting the threshold of common law duty. Additionally, there was an instance of a resident potentially being confined due to a hook and eye lock installed on the outside of a bathroom door.
• Infection Prevention and Control Lapses: The facility failed to adhere to standards set for infection prevention and control. This included inadequate supplies of personal protective equipment (PPE) for staff, insufficient hand hygiene practices during meal services, incorrect signage for residents on droplet contact precautions, and inappropriate PPE usage by staff.
• Issues with Doors in Non-Residential Areas: Doors leading to non-residential areas were not kept closed and locked when unsupervised, posing a risk to residents.
• Delayed Reporting of Critical Incidents: The facility was late in reporting an outbreak of a disease of public health significance to the Director.
• Compliance Order for Transferring and Positioning Techniques: A compliance order was issued due to the failure in ensuring safe transferring techniques, which had led to a resident sustaining injuries.

April 2022 ✅

There were no findings of non-compliance. The report was completed by Cathi Kerr.

This inspection was conducted in reference to intake log #011942-21 related to alleged staff misappropriation of ministry funding; and intake log #018800-21 related to alleged staff to resident abuse.

June 2021 🔎

A critical incident system inspection by Sarah Gillis. The inspection spanned several days, from June 2 to 10, 2021.

The inspection focused on several critical incidents, including allegations of staff neglect towards a resident, two incidents involving falls resulting in injuries, and another incident causing injury to a resident.

Specifically, the licensee was found to have failed to ensure that the care outlined in a resident’s care plan was provided as specified. This involved a case where Resident #004 was not adequately supervised during a daily living activity, contrary to the care plan which required two staff members for assistance and hourly safety checks. As a result, the resident was left unattended for several hours, posing a significant risk to their well-being.

Fairhaven was issued a written notification of non-compliance. They are requested to prepare a voluntary plan of correction to ensure that care is provided in accordance with the residents’ care plans.

January 2021 🚨

The inspection was completed by Sarah Gillis.

• Non-Compliance in Continence Care and Bowel Management: The care provided to residents #005, #007, #008, #009, and #010 was not in line with their individual care plans, particularly regarding continence care. Personal Support Workers (PSWs) #107 and #108 were reported to have used inappropriate techniques in providing care and refused to assist a resident who requested toileting. This neglect put the residents at risk of negative outcomes, such as altered skin integrity, and demonstrated a disregard for the specified care requirements.
• Failure to Adhere to Zero Tolerance Policy for Abuse and Neglect: The facility did not comply with its own zero tolerance policy regarding abuse and neglect of residents. Specific instances were highlighted where PSWs did not report observed or suspected abuse immediately, as required by the facility’s policy. This included multiple instances of resident neglect by PSWs #107 and #108, which were not reported in a timely manner. Such lapses in reporting are critical as they can delay necessary interventions and undermine the safety and wellbeing of residents.
• Insufficient Assistance with Dining and Snack Service: The facility failed to comply with regulations ensuring that residents have enough time to eat at their own pace. There were several observations where PSWs #107 and #108 prematurely removed food from residents #004, #005, #008, and #009 before they had finished eating. This practice is especially concerning for residents who are slow eaters or require assistance and encouragement to eat. This failure not only disrespects the residents’ autonomy and dignity but also poses risks to their nutritional health.

July 2020 ✅

There were no findings of non-compliance. The report was completed by Chantal LaFreniere.

June 2020 🚨

A complaint inspection was conducted by Sarah Gillis. This inspection, carried out between February 11 and February 24, 2020, was initiated in response to a complaint related to resident care, medication management, complaints handling, and issues regarding falls.

• Non-Compliance with Medication Management Policies: The facility failed to comply with its own medication management policies, specifically those regarding the readmission of residents from hospitals. This included lapses in processing medication orders upon a resident’s readmission, resulting in incorrect medication administration. In one instance, resident #002 did not receive specific medications for three days after being readmitted from the hospital, due to failure in initiating checks of readmission orders and inaccuracies in the Medication Administration Record (MAR).
• Failure in Administering Drugs as Prescribed: The inspection found that the facility did not administer drugs to residents in accordance with the prescriber’s directions. For example, resident #002 was given incorrect doses of medications and received medications that were not prescribed, due to delays in processing readmission orders and failure to update the electronic medication administration record (eMAR) in a timely manner.
• Non-Compliance in Forwarding Written Complaints: The facility did not comply with the requirement to immediately forward written complaints to the Director. A specific instance involved a written complaint from the Substitute Decision Maker (SDM) for resident #002, which was not forwarded to the Director as mandated. The complaint, which was related to the care of resident #002, was recorded in the facility’s complaint log but not appropriately escalated.

March 2020 ✅

There were no findings of non-compliance. The report was completed by Sarah Gillis.

January 2020 🚨

On January 7, 2020, a critical incident system inspection was conducted at Fairhaven, a long-term care home in Peterborough, Ontario. This inspection, which took place over several days in November and December of 2019, was in response to various critical incidents, including falls, abuse, care of a resident, and bed entrapment.

• Non-Compliance with Bed Rail Regulations: The facility failed to comply with regulations regarding the use of bed rails. It was found that residents had not been adequately assessed, and their bed systems were not evaluated as per evidence-based practices to minimize risk. A specific incident involving resident #009 highlighted this issue, where the resident became entrapped in the bed rail, resulting in injury. Interviews and reviews conducted during the inspection revealed that the home had not been completing necessary bed rail assessments for residents who used bed rails, and there were discrepancies in the documentation and actual bed rail systems in use for several residents.
• Failure in Implementing Care Plans: The licensee did not ensure that the care set out in the care plans was provided as specified. For instance, resident #005 was left unattended during continence care and did not have the call bell within reach, contrary to the specified care plan. This oversight in following the care plan led to an incident where the resident was injured.

As a result of these findings, the facility was issued written notifications of non-compliance and a compliance order. The order required the licensee to evaluate all bed systems in the home, take immediate corrective actions for any non-compliant bed systems, maintain a detailed bed system inventory, and reassess the use of bed rails for all residents. Additionally, they were instructed to ensure that care plans, especially regarding toileting and falls prevention, are properly implemented and followed.

December 2019 🚨

A complaint inspection was conducted Inspector Chantal Lafreniere. This inspection, which took place over several days in November and early December 2019, focused on issues related to medication administration.

The inspection revealed a specific instance of non-compliance related to the facility’s medication management policies. The facility failed to ensure compliance with its Medication Reconciliation policy, as required under the Long-Term Care Homes Act, 2007 (O.Reg 79/10, s. 8). This policy mandates the recording of a complete and accurate list of a resident’s current and pre-admission medications, including their name, dosage, frequency, and route, along with the sources of medication information.

A critical incident report (CIR) related to medication administration involving resident #003 triggered the inspection. An examination of the resident’s clinical health record and the Best Possible Medication History (BPMH) form revealed inaccuracies in the recording of medication information by RN #124. Specifically, RN #124 failed to list the resident’s medications correctly on the BPMH and did not identify the sources used to verify the medications, using only one source instead of the required multiple sources.

During the inspection, the Director of Care (DOC) acknowledged that RN #124 had inaccurately recorded the medication information for resident #003. The Resident Care Manager (RCM) noted that following the incident, the medication reconciliation policy was reviewed, and changes were implemented in the facility’s practices.

As a result of these findings, the facility was issued a written notification of non-compliance and was requested to prepare a voluntary plan of correction to ensure adherence to the medication reconciliation policy.