County fined for ongoing non-compliance issues at Sunset Manor


Admission ban remains in place with 43 beds now empty; county says plan is underway to reopen in ‘near future’

The province fined the county for continued non-compliance with provincial standards at Sunset Manor.

Simcoe County, as operator of the Sunset Manor long-term care home, was fined $5,500 by the province for failing to comply with provincial medication management requirements.

The fine was issued with a recently released inspection report from the Ministry of Long-Term Care, which cites other instances of non-compliance in administering medication to residents.

County Health and Emergency Services General Manager Jane Sinclair said the fine is a new measure under the Long-Term Care Home Fixing Act and is applied when a compliance order is reissued upon inspection.

“We will continue to work with the province to better understand these new standards and how we can work together to achieve our shared goal of service excellence,” Sinclair said in a statement emailed by the county’s communications department.

“We value feedback from our provincial partners and remain committed to ensuring that all efforts are focused on areas for improvement.”

An inspection by the Ministry of Long-Term Care conducted throughout May and released at the end of July included eight written notices of findings of non-compliance with Ontario regulations dealing with medication management, skin care and sores; falls prevention and management; prevention of abuse and neglect; and food, nutrition and hydration.

The May 2022 inspections were carried out by three ministry inspectors and the report resulted in a compliance order related to home medication management.

The report says there were 94 medication incidents at home between April 2 and May 9, 2022, including two omissions, one missed dose, four missed signatures and 87 medications administered at the wrong time.

Sunset Manor has been under a new entry ban since June 2021; the ban was ordered by the Ministry of Long-Term Care after several reports of non-compliance dating back three years and documented in inspection reports.

The county challenged the admission ban in court, alleging it was an overreaction prompted by reports from a former employee who is now a provincial inspector.

The province countered that the ban was and still is necessary based on multiple reports from multiple inspectors before and after the ban was put in place. The province’s position is that the entry ban would have been justified even without any of the evidence presented by the former Sunset Manor employee.

Simcoe County confirmed today (August 4) that 43 of Sunset Manor’s 148 beds are empty.

The medication incidents cited in the July report involved five different residents. One was given painkillers more than an hour late twice in eight days according to incident reports.

Another resident did not receive the first dose of a new medication on the evening the prescription was to begin.

A resident was given medication while being treated for a hypoglycemic (low blood sugar) event and the protocol to withhold insulin and contact a physician immediately was not followed.

Another resident received medication when his blood pressure was low, despite orders not to take medication when blood pressure was low. Incidents similar to this, related to the administration of insulin to residents with hypoglycemia, were also investigated during winter inspections and were included in the report published in May.

According to the report released in July, a resident who was to receive medication if his blood pressure was high did not receive the medication for five days while his blood pressure was high.

Finally, a resident whose medication had to be withheld if his blood pressure dropped below a certain threshold received medication twice while the blood pressure was listed on the charts as “not applicable”.

According to the ministry’s inspection, no incident reports have been created for medication incidents related to blood pressure.

The inspection notes that two of the care directors at Sunset Manor acknowledged that the medications had not been administered as prescribed.

As a result of these medication incidents, one resident experienced pain, one required additional monitoring and three others were at risk of adverse health effects, the inspector’s report said.

Since there was already an outstanding compliance order following inspections conducted in January and February regarding similar issues, the department issued a fine of $5,500.

The winter 2022 compliance order states that the home must ensure that medications are administered according to the prescriber’s instructions, and that if this does not occur, an incident report is completed.

Inspection reports from January/February and May 2022 indicate a history of non-compliance by the home in the area of ​​medication administration.

Between December 31, 2021 and January 24, 2022 (25 days), there were 470 medication incidents, including one wrong medication administered, two medications not administered, 19 missing signatures, one delivery incident and 447 medications administered at the wrong time. .

In the July 2022 report, the county was granted a deadline of August 17, 2022 to comply with five actions in the order. Documentation proving that the actions were done should be kept at home.

First, the county must ensure that the five residents on the last inspection report receive medication according to the instructions given by the prescriber by performing daily audits for two weeks.

All staff in the Collingwood 2 home area should receive a review of the reporting/alert system in the electronic medication administration record.

Two staff members identified by the ministry are to be “re-educated” on the home’s policies for managing diabetic residents and handling hypoglycaemic incidents.

The county must provide training to all staff registered at home for administering medication with specific blood pressure and/or heart rate parameters.

The home should develop and implement an audit to ensure that medications are stored according to blood pressure and/or pulse parameters and that prescriber instructions are followed.

The fine is due within 30 days.

The latest inspection report said the home had complied with two other previous orders regarding documenting procedures and/or actions taken against residents and ensuring that all staff participated in the home’s infection control program. According to inspectors, the home complied with the terms of both orders.

Two other abuse-related complaints were flagged as “closed” in the July report.

Sinclair, in his statement, said the home and the county were pleased that the May inspection resulted in the removal of four of the five compliance orders inspected during the review.

“This significant achievement highlights the number of improvements that have been made to Sunset Manor,” Sinclair said. “We are confident that we are getting closer to achieving admissions in the near future, and our team has developed a transition plan to quickly and seamlessly welcome new residents into the home once the stop-loss order is released. admissions will have been lifted.”

In an emailed statement, also sent through county communications staff, Superintendent George Cornell called the “lifting of four compliance orders” a “positive step forward.”

“Simcoe County Council is extremely supportive of Sunset Manor and all of our long term care and seniors services offered throughout the area,” Cornell said. “County Council is monitoring the situation closely and continuing to provide information and advice as the home works to achieve full compliance.”

Simcoe County operates four long-term care homes in Simcoe County, including Sunset Manor, Simcoe Manor (Beeton), Georgian Manor (Penetanguishene) and Trillium Manor (Orillia).

You can read the Ministry of Long-Term Care’s most recent inspection report on Sunset Manor here.


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