Wentworth Lodge (41 South Street West, Dundas) is a nursing home that is owned and operated by the City of Hamilton.. There are approximately 160 beds in private, semi-private, and two-person rooms.
Inspection Reports for Wentworth Lodge
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for Wentworth Lodge. You can read the original copies of the reports in the Government of Ontario website.
July 2023
The inspection, conducted by Dusty Stevenson, outlined several non-compliances.
- Plan of Care: The licensee failed to provide clear direction to staff regarding falls interventions for a resident. In June 2023, a resident was observed with a falls intervention in place on one side of their bed, but the plan of care did not specify the placement of this intervention. Staff members and the home’s Falls Lead indicated that the resident required falls interventions on both sides of their bed. The plan of care was revised in July 2023 to reflect this requirement. Due to unclear direction in the plan of care, the resident did not receive the necessary falls interventions, increasing their risk of injury.
- Pain Management: The licensee did not comply with the pain management program for assessing a cognitively impaired resident who could not communicate their pain. The home’s procedure required using the PAINAD assessment scale for non-communicative/cognitively impaired residents. However, a staff member used the numerical scale instead of the PAINAD scale 150 times over 40 days for assessing a cognitively impaired resident’s pain. This non-compliance put the resident at risk of having unmanaged pain due to inappropriate pain assessment.
February 2023
The inspection report, conducted by Stephanie Smith and Barbara Grohmann, outlined several non-compliances.
- Plan of Care Update: The licensee failed to revise the plan of care when a resident’s care needs changed, specifically not including a chair alarm as a falls prevention intervention. This was later updated and the plan of care was revised on February 2, 2023, to include the chair alarm.
- Skin Surveillance: The home did not provide care as specified in the resident’s plan of care related to skin surveillance. Personal Support Workers did not complete skin surveillance during baths as required, which could lead to missed incidents of altered skin integrity.
- General Requirements for Programs: Actions taken under the nursing and personal support services program, especially related to continence product changes, were not documented. Continence changes during the night shift were not documented on several occasions, leading to inconsistent care.
- Plan of Care: The licensee failed to revise a resident’s plan of care when their Substitute Decision Maker (SDM) requested meal trays to be left in the resident’s room, potentially failing to provide care in accordance with the resident’s needs.
- Infection Prevention and Control Program: There was a failure to implement the Infection Prevention and Control (IPAC) Standard for Long-Term Care Homes. A Screener performed a COVID-19 rapid antigen test without proper PPE, including eye protection, and improperly used gloves for other tasks, increasing the risk for transmission of infection.
- Reporting and Complaints: The licensee failed to inform the Director immediately when a complaint alleging neglect was received. A critical incident report about a complaint from a resident’s SDM was submitted to the Director 10 days after receipt.
January 2023
The inspection report identified a specific non-compliance.
The licensee failed to ensure that a designated Infection Prevention and Control (IPAC) lead worked regularly on-site at the home for the required minimum hours. The IPAC lead, who also had shared IPAC responsibilities with another home, was unable to fulfill the minimum of 26.25 hours per week as mandated for a home with a licensed bed capacity of more than 69 beds but less than 200 beds. This issue was acknowledged by the Director of Care (DOC), who confirmed that the position was currently unfilled, and the home was actively recruiting for the role.
March 2022
During the inspection, several non-compliances were identified.
- Duty to Protect: The licensee failed to ensure that two residents were protected from abuse. In one case, a resident was witnessed inappropriately touching another resident who was unable to give consent due to severe cognitive impairment. In another incident, a resident sustained injuries after an interaction with another resident, which was acknowledged as physical abuse.
- Administration of Drugs: The licensee did not administer medication to a resident according to the doctor’s specified directions. This failure posed a risk that the resident’s medical condition was not managed effectively.
- Policies: The licensee did not ensure compliance with its own policies. Specifically, the staff did not follow the policy which stated that any as-needed medication administered should be documented in the electronic progress notes, noting the date and time the medication was given and its effect. There was a discrepancy in the documentation regarding the amount of medication given to a resident.
Additionally, a compliance order (CO #001) was issued to ensure that residents are protected from sexual and physical abuse. This order was made considering the severity and scope of the non-compliance, as well as the home’s compliance history.
January 2021
During the inspection at Wentworth Lodge conducted by Yuliya Fedotova, it was found that there were no non-compliances issued.