Isabel and Arthur Meighen Manor

Isabel and Arthur Meighen Manor (155 Millwood Road, Toronto) is operated by The Governing Council of The Salvation Army in Canada. The facility has a capacity of approximately 168 beds.

In this article, our Good Caring Canada team has reviewed Isabel and Arthur Meighen Manor 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 Isabel and Arthur Meighen Manor.

Table of Contents:

• Inspection Reports for Isabel and Arthur Meighen Manor
• Performance Indicators for Isabel and Arthur Meighen Manor
• Resident Profile of Isabel and Arthur Meighen Manor

Inspection Reports for Isabel and Arthur Meighen Manor

Isabel and Arthur Meighen Manor 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 Isabel and Arthur Meighen Manor. Original copies of the inspection reports can be read in the Government of Ontario website.

🔍  March 2024: Inspection

The inspection for Isabel and Arthur Meighen Manor addressed three main areas of non-compliance. The issues involved directives by the Minister, infection prevention and control protocols, and adherence to residents’ plans of care.

• Directives by Minister: The licensee failed to comply with the Minister’s Directive regarding COVID-19 response measures. Two staff members were observed not wearing required medical masks in resident areas. One staff member admitted to knowing the mask requirement but failed to wear one, while another forgot to don a mask before entering the resident’s home area. This non-compliance increased the risk of infection transmission to residents, staff, and visitors.

• Infection Prevention and Control: The licensee did not implement the required infection prevention and control standards. Specifically, incorrect point-of-care signage led to staff using inappropriate personal protective equipment (PPE). A staff member did not wear the required eye protection due to incorrect signage indicating the type of precautions necessary. This failure posed a risk of improper infection control measures being applied.

• Plan of Care: The licensee failed to ensure that the care set out in residents’ plans of care was provided as specified. First, a resident requiring constant supervision for personal hygiene was left unattended by a PSW, resulting in a fall and subsequent death due to injury. Second, a resident did not receive a scheduled treatment on time, resulting in approximately eight additional hours of treatment, which posed a risk of harm. In the last instance, a resident needing a specific intervention at all times was observed without it, due to a PSW’s misunderstanding, putting the resident at risk for skin breakdown.

🔍  October 2023: Inspection

The inspection for Isabel and Arthur Meighen Manor addressed three main areas of non-compliance. The issues involved plans of care, required programs, and critical incident reporting.

• Plan of Care: Isabel and Arthur Meighen Manor failed to ensure that the care set out in resident #001’s plan of care for fall prevention and toileting was provided as specified. Resident #001 lacked fall prevention logos on their mobility device and bed, which PSW #105 and RPN #106 were unaware of, posing a moderate risk. Additionally, PSW #105 left resident #001 unattended during toileting, causing a fall and injury due to the absence of necessary supervision and mobility device, contrary to the care plan.

• Required Programs: The licensee did not comply with their Falls Prevention and Management policy related to post-fall management.

• Resident #002 had an unwitnessed fall, and although a head injury routine (HIR) was initiated, it was not completed as required. RPN #103 confirmed the lapse, and the DOC acknowledged non-compliance with the policy, which placed the resident at risk for further injury.

• Critical Incident Reporting: The licensee failed to ensure that the Director was immediately informed about an outbreak of a communicable disease. An outbreak declared by the Public Health Unit on September 1, 2023, was reported to the Ministry of Long-Term Care only on September 5, 2023. The DOC admitted the delay. Although the home initiated outbreak measures, the late reporting posed a low risk to resident

🔍  August 2023: Inspection

The inspection for the Isabel and Arthur Meighen Manor addressed multiple intakes involving resident bill of rights, plan of care, duty to protect, reporting to director, training, responsive behaviours, infection prevention and control, visitor policy, website, and transferring and positioning compliance.

• Resident Bill of Rights: The licensee did not ensure that Personal Support Workers (PSWs) #112 and #114 treated Resident #004 with respect and dignity. Video footage showed these PSWs discussing the resident’s personal health information in their presence, posing a risk of emotional harm. This was confirmed by the Physiotherapist (PT) and Director of Care (DOC).

• Plan of Care: The Isabel and Arthur Meighen Manor did not ensure that the care set out in residents’ plans of care was provided as specified. For Resident #003, the care plan lacked clear directions, leading to inconsistent interventions for their responsive behavior. Additionally, Resident #004’s specified fall prevention intervention was not applied, resulting in a fall incident. These issues posed risks to the residents’ safety, confirmed through reviews and interviews with relevant staff.

• Duty to Protect: The licensee failed to protect Resident #005 from verbal abuse by PSW #122. Video footage revealed the PSW speaking to the resident in a loud and belittling manner. This incident caused emotional harm and was acknowledged as verbal abuse by the DOC.

• Reporting to Director: The licensee failed to ensure immediate reporting to the Director of an incident involving improper care that resulted in harm to Resident #002. The incident, which involved a significant injury, was not reported until a week later. This delay could have resulted in delayed corrective actions.

• Training: The licensee did not ensure that agency staff received required training before performing their responsibilities. Several PSWs began working without completing the necessary training, increasing the risk of incompetent care and treatment. This was confirmed by a review of training records and interviews.

• Responsive Behaviors: The Isabel and Arthur Meighen Manor failed to document actions taken to respond to Resident #001’s responsive behaviors. An assessment for the responsive behavior intervention was not completed, risking the identification of behavior triggers and appropriate interventions.

• Infection Prevention and Control (IPAC): PSWs #112 and #114 did not follow proper IPAC practices, using the same gloves for multiple tasks for Resident #004. This increased the risk of cross-contamination, as verified by the IPAC Lead.

• Visitor Policy: The visitor log was incomplete, missing full names, contact information, and resident names visited. This non-compliance was acknowledged by the Executive Director (ED).

• Website: The home’s public website lacked essential information, including contact details for senior staff, complaint procedures, quality improvement reports, visitor policy, and emergency plans. This was confirmed through a review of the website and interviews with the ED.

• Accommodation Services Compliance: The licensee did not ensure that the home and equipment were maintained in a good state of repair. Multiple resident rooms had broken window stoppers and missing operating window handles. These issues included windows that could open wider than the safety limit of 15 centimeters. An incident involving Resident #003, who exhibited responsive behavior due to a broken window stopper, highlighted the risks. The inspection revealed continued issues with window stoppers and handles in several rooms, and delays in addressing maintenance requests. The inspector mandated an auditing process to ensure compliance. This involves auditing all resident-accessible windows for condition, repairing any issues, installing operating handles, establishing a regular audit schedule for maintenance, and maintaining thorough audit records. These steps aim to mitigate safety risks and enhance window maintenance at the facility.

• Transferring and Positioning Compliance: The licensee did not ensure staff used safe transferring and positioning techniques for multiple residents. Incidents included improper manual transfers, contrary to the Zero Lift Policy, and failure to follow specified transfer methods in care plans. An auditing process was ordered to ensure compliance, including staff education and frequent audits with corrective actions.

🔍  June 2023: Inspection

The inspection for the Isabel and Arthur Meighen Manor addressed several main intakes involving improper care and non-compliance with care plans and policies.

• Plan of Care: The licensee did not ensure that residents #003 and #004 were assisted with care after eating as specified in their care plans. PSWs admitted to not providing the required care for Resident #003, which was acknowledged by the RPN and DOC. Similarly, Resident #004 was not given the necessary post-meal care, confirmed by observations and PSW admissions. The failure to provide this care put residents at risk of medical concerns and skin breakdown.

• Effectiveness of Care Documentation: The licensee failed to document the effectiveness of Resident #001’s care plan related to incontinence products. Despite indicating a trial period for the product, the care plan was not updated after the trial. The DOC confirmed that while the effectiveness was reviewed, it was not documented, leading to inaccurate records.

• Safe Transferring Techniques: The licensee did not ensure the use of safe transferring techniques for residents. A PSW forcefully transferred a resident out of bed, contrary to their care plan, which required assistance from two staff and specified not to grab and pull the resident. This improper transfer, verified by the PT, posed a risk of injury to the resident.

• Nutritional Care and Hydration: Proper techniques to assist a resident with eating were not followed. Evidence showed a staff member forcefully assisting a resident who was resisting. The Registered Dietitian confirmed the improper technique and retrained the staff member. This failure increased the risk of aspiration for the resident.

• Infection Prevention and Control (IPAC): The licensee did not perform required IPAC audits every two weeks as per the Minister’s Directive for COVID-19 response measures. An audit was missed in March 2023, putting residents at risk of infectious diseases.

• Reporting and Complaints: The licensee did not provide the Ministry’s toll-free number and contact details for the Patient Ombudsman in responses to complaints. Complaints related to residents #001, #004, and #006 did not include this required information, as acknowledged by the DOC and ADOC.

• Forwarding Complaints to the Director: The licensee failed to confirm in responses to complaints that they were forwarded to the Director as required. Complaints from Resident #001’s SDM and another regarding Resident #004 did not indicate if they were reported to the Ministry of Long-Term Care. The DOC and SDM acknowledged this omission.

• Incident Reporting: The licensee did not include the name of the PSW involved in an incident in a report to the Director. A CIR related to improper treatment of a resident did not list the PSW’s name, only the RPN’s. The DOC admitted this might have been an oversight.

🔍  January 2023: Inspection

The inspection for Isabel and Arthur Meighen Manor addressed multiple issues, including a failure to comply with hand hygiene standards, reporting critical incidents, and implementing strategies for responsive behaviors.

• Non-Compliance Remedied: Non-compliance was found regarding hand hygiene prgram and remedied by the licensee before the inspection concluded, satisfying section 154 (2) requirements.

• Hand Hygiene Program: The licensee did not ensure the hand hygiene program was implemented per standards, specifically regarding the use of Alcohol-Based Hand Rub (ABHR). Observations identified a bottle of ABHR with only 60% alcohol, which was not as effective. The RPN acknowledged this and removed the bottle. Additionally, seven expired ABHR bottles were found and immediately removed by RPNs and the ESM. Audits were initiated, and expired ABHRs were removed and replaced. Regular audits were planned to prevent recurrence.

• Reporting Critical Incidents: The licensee failed to report a resident’s fall that resulted in injury and a significant health change to the Director within one business day. The resident was hospitalized, diagnosed with an injury, and passed away seven days later. The DOC admitted the critical incident should have been reported once the injury was confirmed. The delay in reporting posed low impact and risk to the resident.

• Responsive Behaviors: The licensee did not ensure strategies were implemented for a resident demonstrating responsive behaviors. Despite developing interventions like the Stop and Go approach, the PSW did not follow it. The BSO Lead acknowledged that not implementing this intervention could increase the resident’s behaviors. The failure to apply the specified strategy was confirmed through interviews and care plan reviews.

Performance Indicators for Isabel and Arthur Meighen Manor

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 Isabel and Arthur Meighen Manor 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 Isabel and Arthur Meighen Manor

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.