Peter D Clark Long Term Care Centre (9 Meridian Place, Ottawa) is a nursing home that is owned and operated by the City of Ottawa. There are approximately 220 beds.
Inspection Reports for Peter D Clark Long Term Care Centre
Our research team carefully reviewed and summarized inspection reports for Peter D Clark Long Term Care Centre. You can read the original copies of the reports in the Government of Ontario website.
🔍 October 2023: Inspection
The inspection report for the Peter D Clark Long Term Care Centre, conducted by Severn Brown and Marko Punzalan, focused on complaints and critical incidents, including alleged family to resident abuse, complaints regarding care decisions and resident care, a breach of confidentiality allegation, and an unwitnessed fall of a resident causing injury and a change in condition.
- Documentation of Plan of Care: The inspection revealed non-compliance regarding the documentation of the plan of care for a resident. Specifically, there was a failure to document required hourly rounding for a resident, which was implemented as a safety and fall prevention measure. This omission was discovered upon reviewing the Resident Safety/Comfort Rounding Sheets, where missed entries were identified over six separate dates. Both a Personal Support Worker (PSW) and the Manager of Resident Services acknowledged that hourly rounding should be documented, but it was found to be missing or incomplete.
- Risk to Resident’s Safety: The lack of documented hourly rounding poses a risk to the resident’s safety, as it affects the clarity of communication regarding the resident’s status among staff members. This could lead to inadequate monitoring and increased risk of falls or other safety concerns.
🔍 August 2023: Inspection
The inspection at the Peter D Clark Long Term Care Centre, conducted by Karen Buness, Kelly Boisclair-Buffam, and Shevon Thompson, focused on addressing various complaints and critical incidents.
This inspection involved examining several intakes, including suspected staff to resident neglect, improper resident care resulting in falls, suspected verbal abuse, concerns about staff qualifications, and multiple incidents of residents falling, leading to significant changes in their health status.
- Non-Compliance with Plan of Care: The inspection found that the licensee failed to adhere to the care related to toileting as specified in a resident’s plan of care. This resident, identified as being at risk for falls and requiring assistance from two persons for toileting, was found on their bathroom floor on a specified date. The plan of care explicitly stated that the resident should not be left unattended while on the toilet. However, this guidance was not followed, resulting in the resident falling to the floor when left alone.
- Failure to Report to the Director: There was also non-compliance regarding the reporting of incidents to the Director. A Critical Incident System (CIS) report related to improper or incompetent treatment of a resident that resulted in harm was not submitted promptly. The Resident Care Manager #100 acknowledged that such incidents should be reported immediately to the Director, but in this case, the required action was delayed.
🔍 May 2023: Inspection
The inspection at the Peter D Clark Long Term Care Centre, led by Erica McFadyen and Karen Buness, focused on various cases of falls resulting in injury, complaints regarding resident care, allegations of physical and verbal abuse, and claims of staff neglect and sexual abuse among residents.
- Plan of Care: The inspection identified a failure to follow the care plan for a resident (resident #004), which resulted in a fall causing serious injuries and subsequent death. It was found that a specific intervention outlined in the resident’s falls plan of care was not in place at the time of the fall, despite being indicated as necessary.
- Abuse and Neglect Policy: There was a failure to comply with the “Resident Abuse and Neglect Policy 750.65”. This involved incidents of alleged sexual contact between residents (resident #005 and #006) and a physical altercation between two other residents (resident #007 and #008). In these cases, the required procedures and reporting mechanisms outlined in the policy were not followed by the staff.
- Responsive Behaviours Protocol: The care plan of resident #001, who exhibited a history of responsive behaviors and was involved in multiple incidents with co-residents, lacked strategies to prevent, minimize, or respond to these behaviors. This omission increased the risk of negative interactions with co-residents.
🔍 September 2022: Inspection
The inspection at the Peter D Clark Long Term Care Centre, overseen by Karen Buness and other inspectors, addressed multiple intakes, primarily focused on falls resulting in fractures, alleged staff to resident abuse, resident-to-resident responsive behavior, and concerns relating to the fall of a resident.
The inspection identified a failure in implementing the Infection Prevention and Control (IPAC) program as per the standards set by the Director. This specifically related to residents’ hand hygiene before meals. During the lunch service, it was observed that residents’ hands were not cleaned, contrary to the guidelines. An interview with a Personal Support Worker (PSW) and the IPAC lead confirmed that hand hygiene before and after eating is crucial. This lapse in hand hygiene practices increases the risk of disease transmission among residents and staff.
🔍 August 2022: Inspection
The inspection at Peter D Clark Long Term Care Centre, led by Karen Buness, focused on various complaints related to care delivery, fluid texture and consistency, infection prevention and control, and dining and snack service.
- Dining and Snack Service: The issue was regarding the incorrect preparation of thickened water for a resident who required thickened fluids due to health status. A family member noticed the inconsistency and alerted the staff. Following this incident, staff received training on preparing thickened fluids, led by a Registered Dietician. The training will be reviewed annually, and instructions for preparing thickened fluids have been posted in the servery. The issue was remedied as of July 6, 2022.
- Personal Care: The inspection identified a failure in delivering individualized personal care to a resident. Specifically, the resident’s incontinent brief was not changed as per the scheduled time in the resident’s plan of care, and the resident was not positioned correctly as directed. This lapse resulted in the resident not receiving personalized care on two occasions. The Registered staff and front-line staff confirmed the existence of specific time frames for changing the resident’s incontinent pad and directions for positioning the resident.
🔍 June 2022: Inspection
The inspection of Peter D Clark Long Term Care Centre, led by Amanda Nixon, focused on various intakes, including complaints about the provision of the plan of care, critical incident reports related to falls, unexpected deaths, and resident-to-resident physical abuse, as well as issues related to nursing support services, skin care, and more.
- Critical Incident Reporting: There was a failure to inform the Director within one business day of an incident causing injury to a resident, which resulted in a significant change in the resident’s health condition. The delay in reporting was seven days after the incident. The Manager of Resident Care acknowledged that the responsible manager was not aware of the incident until six days after it occurred.
- Plan of Care Documentation: The inspection found that the monitoring of a resident’s health condition, as ordered for every shift, was not documented in the Electronic Medication Administration Record (EMAR). Both the Manager of Resident Care and a Registered Practical Nurse confirmed that this monitoring should have been documented in the EMAR. The lack of documentation posed a potential risk of undiagnosed complications for the resident.
🔍 June 2022: Inspection
The inspection of the Peter D Clark Long Term Care Centre focused on multiple complaints and critical incident reports related to alleged staff-to-resident abuse. The inspection was led by Amanda Nixon.
- Plan of Care: The inspection identified a failure by a Personal Support Worker (PSW) to provide care as specified in a resident’s mood and behaviour plan of care. The PSW did not implement interventions as required when the resident exhibited responsive behaviours. This failure was documented based on the resident’s plan of care and other digital information.
- Duty to Protect: The PSW was found to have used physical force and threatening, intimidating gestures and remarks towards a resident, especially when the resident began to show responsive behaviours. The PSW then left the resident alone, failing to provide necessary care. The actions of the PSW potentially escalated the resident’s responsiveness, increasing their risk of injury. This finding was supported by digital information.