In one case, a helpless 71-year-old Toronto woman with advanced dementia was raped in her bed, allegedly by a male nurse identified months earlier by other staff at the home as someone who regularly disappeared on shift “without explanation.”
A staff member discovered the male nurse in Danae Chambers’ room in the middle of the night. Chambers, a renowned portrait artist, lay sideways on her bed and the male nurse, pants dropped to his knees, stood against her bare buttocks, according to a provincial inspection report.
“I trusted them to take care of her,” said Chambers’ close friend and guardian, Anna Schrofer. “I tried so hard to find the right home for her and everyone said this was the best.”
In another case, this one in a North York nursing home, a staff member first physically assaulted a resident, then warned a witness “not to tell anyone,” a provincial inspector found. Two staff members who were aware of the abuse didn’t report it.
A worker at a Port Dover home “cuffed” a resident on the head, another inspection report said.
There were at least a dozen cases in which the attacks were so serious, ministry inspectors determined the home should have immediately notified police. But the homes delayed and sometimes never bothered calling the cops — pointing to a culture of secrecy in some nursing homes
Seniors advocates agree that cases of abuse in long-term care are under-reported. According to the reports the Star obtained, more than 10 residents in Ontario each month are punched, pushed, verbally abused or sexually assaulted.
In the majority of the known cases, the abuser was a staff member. In others, the assault was resident on resident.
Eight years after Star stories documenting problems brought a provincial vow of improved care, the same problems exist.
The problems continue because the nursing home system is taking increasingly sick and demented residents but lacks the money for increased staffing levels to provide a minimum amount of daily care.
Personal support workers who do the majority of hands on work are not regulated and have little training to manage residents with complex needs.
What has changed is the Ministry of Health and Long-Term Care’s inspection system. Just over a year ago the ministry rolled three confusing nursing home acts into one piece of legislation in response to a 2003 Star investigation.
The new inspection system — with a focus on resident complaints — is now uncovering hundreds of cases of assault and neglect.
The Star obtained more than 1,500 inspection reports carried out since the new rules began. Each inspection was done in response to either a complaint of poor care or the nursing home’s own reporting of a critical incident such as an alleged assault or broken bones from a fall.
The system relies on homes volunteering negative information about themselves or residents speaking out, even though many fear repercussions.
Of 1,500 inspection reports (the Star obtained about 70 per cent of reports from the last year), serious problems were found in 900 cases. Of those, roughly 125 were abuse related, 350 revealed neglectful treatment of a senior and the remainder found other types of poor care. There are 627 homes in Ontario with 77,000 residents.
Today’s story focuses on abuse.
In the case of well-known Canadian portrait artist Danae Chambers, police have laid a sex assault charge against a male registered practical nurse, a job that requires two years of college training compared to a current registered nurse’s four-year university degree. The case is before the courts.
Back in the 1970s and 1980s, Chambers painted elite political, business and literary figures. Former Prime Minister Pierre Trudeau was one of her subjects.
Earlier, she studied art at the University of Oxford and for many years lived in Menton, in the south of France, where she created oil paintings of the region’s lush gardens.
Chambers began showing signs of dementia in the early 1990s and by 2006 was a resident of Castleview Wychwood Towers, a City of Toronto-run nursing home.
Her brother in British Columbia asked her close friend, Anna Schrofer, to be power-of-attorney. Schrofer visits her regularly and uses money from the sale of Chambers’ paintings to pay for a private worker to provide extra care. Chambers is divorced. She has a son whose whereabouts is unknown to the family.
“This is a woman who can do absolutely nothing. She cannot speak, she cannot stand, she is totally reliant,” said Schrofer.
Chambers lives in a tiny, shared room. Though victims of sexual assault are not usually identified in the media, Schrofer and Chambers’ brother, Parker Williams, said they wanted her name used to draw attention to the dangers vulnerable women face in nursing homes.
“It was shocking, improper and it should be stopped,” Williams said.
In Chambers’ case, the provincial inspection report reveals that the home was warned by a staffer two months before the alleged attack that a male registered practical nurse who was supposed to be watching “high risk” residents in one area was “returning late from breaks and (had) unexplained absences from his assigned duties.”
According to ministry reports, he was discovered in Chambers’ room on April 4.
At 3:05 a.m., a staff member saw a male nurse standing at Chambers’ bedside, his pants halfway down his legs.
The man was standing behind Chamber’s exposed buttocks, which were “positioned at the edge of the bed.” His body was “facing (Chamber’s) buttocks.” The bed had been positioned at a height between his hips and waist.
According to the report, her back and breasts were exposed; fluid was coming out of her mouth and her eyes were open.
Chambers’ diaper was lying on her wheelchair seat. Three disposable gloves and two wet face cloths were on the floor.
Chambers’ friend, Schrofer, said the worker who witnessed the alleged assault reported it immediately. Schrofer got a call from police early in the morning and she went to the home to comfort her friend.
Leonid Kozlov, now 46, is facing a sex assault charge. He had worked at the home for about five years.
The home’s administrator, Nancy Lew, said she could not comment on the alleged assault, nor on the earlier warnings, because the case is before the courts.
The ministry inspector’s report concluded that the nursing home failed to investigate the earlier allegations.
Ministry officials prepare two very different reports of an incident. One with detailed findings is given to the home’s management. Another version, typically sanitized of key details, is posted in a public place in the nursing home so families and prospective residents can see the kind of care offered in the home.
In Chamber’s case, the posted report is a sanitized version. This happens all the time, the Star found.
The public report does say the home “failed to protect an identified resident from abuse” but does not go into detail, saying only that “a staff member was found on an unassigned unit.”
The home’s version gives precise details of the alleged assault and the previous written warnings. The ministry refused to give Schrofer a copy so she found a lawyer at the Advocacy Centre for the Elderly who got it for her.
Most of the 1,500 reports the Star obtained for this story were the sanitized versions.
Reading them, it was impossible to know how many of the abuse cases were actually sexual assaults. There are dozens that found homes failed to “protect” a resident from abuse, but they lack detail.
The sexual assault of elderly women was the focus of a conference held last summer by the International Federation on Aging.
Greg Shaw, the federation’s spokesperson, said the topic was requested by two Liberal ministers, Laurel Broten, now the education minister and former Senior’s Minister Sophia Aggelonitis, defeated in the October election.
In her speech, Broten said that elderly women rarely report sexual abuse, often out of shame, so official statistics are likely very low.
“We need to talk about ways to increase the reporting of sexual abuse of older women,” Broten said.
“We need to start today, discussing how we can better protect and support older women in health and home care settings as well.”
In some cases, people with dementia act out sexually and require intense intervention to protect fellow residents.
Other sexual assault cases found in inspection reports include:
At Leisureworld Brampton Woods, a male resident sexually assaulted an elderly woman. The report said the same man had 18 recent encounters with other residents, all involving sexual assaults, inappropriate touching or verbal abuse. This had been going on for 10 months. The ministry found the home did not properly follow up with the man or the resident he assaulted.
Brampton Woods administrator, Janet Groux, said staff has since received extensive training on follow-up procedures and education on dementia to keep the other residents safe. The home also received special funding from the ministry for a 90-day program that gave the resident one-on-one attention.
The resident needs constant attention because in one case, when a female resident walked past him, he reached out and touched her chest, Groux said.
“This is not the way he was (in life),” she said. “Staff needed to be trained in ways to stop him because he does not know what he is doing.”
At north Toronto’s Valleyview Residence, a staff member learned that a visitor allegedly sexually assaulted a resident but the staffer didn’t report it. The employee didn’t notify anyone until the resident’s family complained about the abuse a second time.
“The staff member made a judgment call, albeit wrong looking back, and didn’t report it to the administration,” said Mike Savatovich, the home’s administrator.
Once management learned of the alleged sexual assaults, the home contacted the ministry and police, he said. The employee was retrained on recognizing and reporting abuse, and the home installed cameras in the hallways.
The Star found about 40 cases where homes delayed or didn’t bother reporting abuse to the ministry, as they are required to.
At Leisureworld Caregiving Centre – Cheltenham, on Bathurst St. near Steeles Ave. West, a staff member abused a resident then told a witness “not to tell anyone,” an inspector found.
At least two staff members knew about the assault and didn’t report it.
When management found out, it reported the assault and fired the abusive staff member, said Lisa Egan, Leisureworld’s vice-president of communications. Education was provided so that “every single person is fully trained and oriented on our zero tolerance policy when it comes to abuse,” she said.
Many employees don’t report abuse because they fear retaliation from their employers, said the president of the Service Employees International Union.
“They are afraid,” said Sharleen Stewart, whose union represents 50,000 Ontario front-line health care workers, including 22,000 in nursing homes.
“Often the administrator tells them not to report (to the ministry), nor to the families or doctors. The administrator says the home will take care of it.
“Many of these workers are new immigrants and are sending money back home. Going to the ministry would open such a big event in their lives, they are afraid to do it.”
Analysis of inspection reports shows aggressive residents — and the homes’ ability to manage their behaviour — is a growing problem.
Dementia levels are on the rise and when elderly people suffer from dementia they can become angry, violent and sometimes overtly sexual.
Nursing home staff need special training because, for example, a worker who rushes a resident with Alzheimer’s out of bed or speaks to them brusquely can turn a routine encounter into a brutal one.
One case, at Extendicare Guildwood in Scarborough, showed that homes have to be constantly on guard to protect residents from harm.
A resident hit her roommate with a hard-plastic “wet floor” sign as the woman lay in bed.
Despite the attack, an inspector found the nursing home “failed to remove the specific object out of the resident’s area.”
The home’s cleaning staff now carries the signs with them when they are not in use, said administrator Andre Barros. The home also moved the assailant to a new room, where Barros said she gets along with her neighbours.
“We as a home try to protect our residents, that’s our top priority,” he said.
A family from Strathroy, near London, complained about a different kind of abuse.
Nancy Eaton said her husband, Brian, 69, was given a powerful drug to stop him from wandering around Strathmere Lodge.
Eaton said before her husband developed dementia he had the ability to fix anything around the house.
Like many with dementia in nursing homes, he was a wanderer who liked to tinker with clocks and furniture. Eaton said he had no problems in his previous nursing home but staff at Strathmere complained that he was aggressive.
“They didn’t take any time to get to know him. He was lost within the building, he didn’t even know where he was,” Eaton said.
Medical records from the home show he was given Haldol, an old version of the anti-psychotic drugs that were used to treat people with schizophrenia.
Two medical geriatric experts, Dr. David Conn of Baycrest and Dr. Paula Rochon of Women’s College Hospital, told the Star the drug has very serious side effects among the elderly, including Parkinson-like tremours, and is not commonly used.
Eaton said her husband had a brain seizure and now, four months later, can no longer wander around the home. He sits in his wheelchair or lies in bed.
The home’s administrator, Tony Orvidas said he has never heard that Haldol should not be given to the elderly. He refused to speak about the case, saying, “I’m not going to get into a pissing match.”
Employees did take action — amongst themselves — to stop a colleague who “cuffed” a resident in the head and was rough with another resident at Dover Cliffs nursing home in Port Dover, near Hamilton.
They did not, however, immediately tell the home’s management so the abuse was not reported to the ministry until five days later.
The abusive employee was fired and all staff members were required to be retrained on the home’s policy on zero tolerance for abuse, said Janet Ko, spokesperson for the home’s parent company, Revera Long Term Care.
The assault happened last April. Three staff heard a resident yell and asked the worker what had happened. According to the inspection report, the worker demonstrated how they “cuffed” the resident on the head.
On the same day, the worker in question was seen feeding a resident in a rough manner.
The resident said, “You are hurting my mouth.”
The worker replied, “Then be quiet and eat your food.”
Data analysis by Andrew Bailey
Moira Welsh can be reached at (416) 869-4073 or firstname.lastname@example.org
Jesse McLean can be reached at (416) 869-4147 or jmclean@thestar.