Golden Plough Lodge (983 Burnham Street, Cobourg) is a nursing home that is owned and operated by Northumberland County. There are approximately 150 beds.
Inspection Reports for Golden Plough Lodge
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for Golden Plough Lodge. You can read the original copies of the reports in the Government of Ontario website.
October 2023: Inspection
The inspection report highlighted several critical issues and non-compliances. The inspection occurred from September 20 to 28 and on October 3, 2023, covering various intakes, including follow-ups on previously issued Compliance Orders and allegations of staff to resident abuse/neglect.
- Reporting Certain Matters to Director: The licensee failed to immediately report to the Director when there were reasonable grounds to suspect incompetent care of a resident that resulted in a risk of harm. Specifically, a critical incident report indicated that the wrong medication was administered to a resident, but this was reported seven weeks after the incident occurred.
- Bedtime and Rest Routines: The licensee did not support a resident’s desired bedtime and rest routines, which are meant to promote comfort, rest, and sleep. A critical incident report described an instance where a personal support worker (PSW) tried to forcibly transfer a resident to bed earlier than their preferred time. The resident felt disrespected, and their comfort and dignity were compromised.
- Administration of Drugs: The licensee failed to ensure that no drug was administered to a resident unless it was prescribed for that resident. In the first instance, an RPN mistakenly administered medication intended for another resident, realizing the error immediately. Despite notifications to management, the physician, and the resident’s family, this constituted a breach of protocol. In another instance, a resident received the wrong medication, reported in a family complaint letter. An RPN acknowledged the mistake, but the incident again highlights the failure to follow proper medication administration protocols.
A re-inspection fee of $500 is applicable due to this being at least the second follow-up inspection for compliance with certain Compliance Orders related to Infection Prevention and Control standards.
June 2023: Inspection
The inspection, led by Basel Mansour and Catherine Ochnik, focusing on various critical aspects of long-term care. The inspection, spanning from May 15 to May 25, 2023, evaluated multiple intakes related to Infection Prevention and Control (IPAC) standards, resident-to-resident interactions, and incidents of alleged neglect and improper care.
- Non-Compliance in Reporting Neglect: The facility failed to immediately inform the Director about an allegation of staff neglect towards a resident. This lack of timely reporting undermines the transparency of the home’s operations.
- Failure to Comply with Compliance Orders: Golden Plough Lodge did not fully adhere to several conditions of previously issued compliance orders. These included IPAC Lead responsibilities, such as conducting audits and developing methods to track and ensure the removal of expired alcohol-based hand rub (ABHR) products. This non-compliance raised concerns about the effectiveness of infection control measures in the facility.
- Issues with Dealing with Complaints: The facility did not provide complete responses to a complainant, lacking essential information like the Ministry’s toll-free number for complaints and contact details for the patient ombudsman. This omission potentially limited the complainant’s ability to seek alternative avenues for their concerns.
- Inadequate Reporting of Incident Details: In reporting an incident of alleged neglect, the home did not include the names of involved or present staff members, compromising the transparency and thoroughness of the report.
As a result of these failures, the facility was issued AMPs totaling $3300 for not complying with specific requirements of the Fixing Long-Term Care Act, 2021. Additionally, due to the necessity of a second follow-up inspection to ascertain compliance with the Compliance Orders, a re-inspection fee of $500 was levied against the facility.
February 2023: Inspection
The inspection was conducted over several days in late 2022 and covered a range of issues, from falls prevention to infection prevention and control, and from abuse and neglect prevention to pain management.
The facility exhibited several areas of non-compliance, including failure to protect a resident from neglect by staff, failing to report verbal abuse immediately to the Director, and not investigating an allegation of financial abuse promptly.
- Inadequate Handling of Abuse and Neglect Allegations: There were instances where the facility did not immediately report or investigate allegations of abuse and neglect, including financial abuse, which potentially exposed residents to ongoing risks.
- Issues with Infection Prevention and Control (IPAC): The facility was found not to be in compliance with IPAC standards, specifically in ensuring appropriate signage for additional precautions and maintaining effective alcohol-based hand rubs.
- Falls Prevention and Management: There were deficiencies in implementing and maintaining an interdisciplinary falls prevention and management program, which put residents at risk for future falls.
The facility was issued Administrative Monetary Penalties (AMPs) for failing to comply with certain orders under the Fixing Long-Term Care Act, 2021. The total penalties amounted to $5,500.
A new compliance order was issued with specific requirements for the facility to improve its IPAC program, including developing and implementing new audit processes and educational programs.
July 2022: Inspection
The inspection report presents a detailed account of the inspection conducted between May 9 and 19, 2022. The inspection was focused on various critical incidents including resident-to-resident abuse, a disease outbreak, resident falls, and alleged staff to resident neglect.
- Hazardous Materials: An issue of improperly labelled hazardous substances was identified and rectified during the inspection.
- IPAC Screening: There was a failure to request contact information as part of COVID-19 screening procedures, which was subsequently corrected.
- IPAC Cleaning Policy: The facility’s cleaning and disinfection policy during outbreaks was not aligned with Public Health Ontario’s guidelines. This was addressed during the inspection.
Several written notifications were issued for non-compliance with different standards, including IPAC Standard 9.1 (G), Plan of Care related to pain management, responsive behaviours, falls prevention, and reporting investigations. These notifications highlighted failures in implementing appropriate care plans, infection control measures, and managing responsive behaviours.
The report includes several compliance orders, requiring the facility to undertake specific actions to address identified issues. These orders cover areas like zero tolerance policy for abuse and neglect, pain management protocols, and infection prevention and control programs.
April 2022: Critical Incident Inspection
During the course of this inspection, Non-Compliances were not issued.
January 2022: Critical Incident Inspection
The inspection report for Golden Plough Lodge, conducted by inspectors Chantal Lafreniere and Julie Dunn, provides a detailed account of various compliance issues identified during the inspection. The primary concerns highlighted include failure to protect residents from abuse, lapses in the implementation of the Infection Prevention and Control program, and shortcomings in notifying relevant parties about incidents of abuse.
- Protection from Abuse: The inspection found that the licensee failed to protect resident #020 from abuse by resident #018. Resident #018 exhibited sexually abusive behavior towards another resident and displayed a pattern of inappropriate behavior. The care home was required to implement interventions and monitoring processes to prevent such incidents. This included educating staff on timely completion of assessment tools and maintaining vigilance to prevent resident-to-resident abuse.
- Infection Prevention and Control: The inspection noted a failure in ensuring all staff participated in the Infection Prevention and Control program. Specifically, during a respiratory outbreak, there was a lack of outbreak signage at the back entrance of the home, which is primarily used by staff and visitors. Additionally, observations indicated that some staff members were not donning appropriate personal protective equipment (PPE) as required. The licensee was ordered to correct these issues by ensuring proper PPE use and adequate outbreak signage.
- Notification and Reporting of Incidents: The report highlighted failures in immediately notifying the Director of Long-Term Care or the resident’s substitute decision-makers about incidents of abuse. This included a delay in reporting an abusive incident involving resident #018. Prompt and transparent communication is crucial for the well-being of residents and for taking appropriate action in response to such incidents.
January 2022: Complaints Inspection
During the course of this inspection, Non-Compliances were not issued.