Octogenarian taken to hospital two days after falling in intermediate resource

INVESTIGATION. It took two days for an 88-year-old resident of Résidence René-Léosa, in Drummondville, to be taken to hospital for treatment after falling. A little more than two years after the death of the octogenarian, coroner Yvon Garneau makes a recommendation to the Integrated University Health and Social Services Center of the Mauricie-et-du-Centre-du-Québec (CIUSSS MCQ ) to prevent such a tragedy from happening again.

The coroner recommends that the CIUSSS MCQ send immediately, before any conclusions of a future work plan, an instruction to all the intermediate residences on its territory to the effect of requesting a medical consultation as soon as a beneficiary a fall and complains of pain.

On June 3, 2020, Marie-Claire Hamel died at the age of 88 from medical complications following a fracture to her left hip. Ten days earlier, Ms. Hamel had fallen from her height in her room, at the intermediate resource.

“In all, three beneficiary attendants (PAB) intervened in the seconds following the fall in addition to a supervisor who was called without delay. Immediately, the vital signs were taken, no injury was observed in the patient and a report with a follow-up request was made and brought to the attention of the evening staff, ”indicates the coroner, in the investigation report.

“At supper, Mrs. Hamel is brought in with the assistance of two PABs, but she cries out in pain and it is feared that she will faint. The evening supervisor, after having been informed of the resident’s illness, does not make too much of it and believes that the latter is pretending to be in pain because, according to her, Mrs. Hamel had a tendency to simulate certain states . Nothing particular is done”, he continues.

The resident is taken back to her room. The next morning, a nurse reads the incident report concerning the fall. The lady, admitted in 2017 to the cognitive unit of the René-Léosa intermediate resource because of her loss of autonomy secondary to her diagnosis of Alzheimer’s-type neurocognitive disorder, is not known to be at risk of falling.

«[L’infirmière] believes, from reading the notes, that Mrs. Hamel was uninjured and only had a stomach ache (expressed upon returning from the dining room where she took nothing but a little ‘water). This nurse does not come to the resident’s room to see, assess or verify. For the latter, stomach aches are common among residents and it is not worth the trip,” writes Yvon Garneau.

During the day, the octogenarian “screams in pain and cries loudly” when it comes time to receive his care. She hasn’t eaten since the fall. The next day, the resident appeared dehydrated, according to notes in her file.

«[En après-midi, des préposées] note (astonished) that Mrs. Hamel is still in her bed and that, really there, it is not normal. Knowing well that she cannot act out, that she is suffering for real, but that people take her seriously seems to be lacking, they insist that the nurse on duty finally come to see her. It is the same nurse who had not thought it necessary to visit her the day before. The supervisor, alerted by these two PABs, had to insist with the nurse that a visit was necessary. The nurse, about an hour later, goes to the bedside of the elderly lady. She sees with her own eyes that the patient has a remarkable bruise on the left buttock and that she had a fever”, can we read.

Marie-Claire Hamel is finally transported to the emergency room of Sainte-Croix hospital two days later. Examinations confirm “the undeniable and trying fracture to the left hip”. No surgery can be considered.

“In the days that followed, inevitably, I can say that the fracture suffered and the strong medication that was administered to her to relieve her of her pain, got the better of her low energy reserves and led to various complications (multifactorial) which ultimately led to his death, which occurred on June 3, 2020 at 6:40 a.m. surrounded by his family, ”reports coroner Garneau.

“Really, the evidence showed in my investigation that the fall which occurred on May 24 caused a fracture of the hip of Ms. Hamel and that she was transported to the hospital two days later. Medical observations were however entered in the portal of the residence and several reports were made to the supervisors concerning the pain and the state of health of the patient without action being taken before May 26, 2020. This situation had nothing to do with simulations or whims coming from a lady who is known to have a cognitive disorder, ”he says.

Measures
The intermediate resource has identified preventive measures to be implemented. Training on the care approach for clients presenting behavioral and psychological symptoms of dementia, like Mrs. Hamel, must in particular be continued for all staff.

An individual reminder was given to each beneficiary attendant, nurse or auxiliary nurse to make sure to visualize the hips adequately, even if the person can move. A reminder would also have been issued to the effect that if an accident with major consequences or risk of major consequences occurred or, if the person’s condition deteriorated, that a notice should be given immediately to the person on duty at the nursing care. If it does not seem to be taken seriously, a gradation in the means of being heard will always be appropriate.

“However, and with respect, the implementation of new measures for emergency management always takes more time than we initially thought. It seems to me, to me and to other coroners who have investigated in similar circumstances elsewhere in Quebec, that when a resident has a fall and complains of pain following the fall, that common sense simply asks to call a doctor without further formality,” says Yvon Garneau.

“I cannot deny a comment from the senior staff of Risk Management to the effect that even in the presence of better communication between the staff of the intermediate resource and the nurse (attached to the CLSC), this would possibly have early identification of the signs and symptoms that overwhelmed Mrs. Hamel, but the outcome (death) would have been the same. It was, it should be remembered, comfort care carefully decreed after a fall which caused a fracture of the hip which, in many cases, gives a poor prognosis for any patient who is inflicted with it. On the other hand, Ms. Hamel could have breathed her last in better conditions,” argues Mr. Garneau.

Recommendations “taken seriously”
The CIUSSS MCQ does not wish to comment on this specific case, the user’s file being confidential. Nevertheless, he indicates that the recommendation of coroner Yvon Garneau “will be carefully evaluated”.

“When we receive a report from the coroner with one or more recommendations, these are taken seriously by our establishment and our actions are part of a concern to improve the quality of our services”, indicates Maude Bourgeois, agent of information to the assistant directorate of organizational and public communications of the CIUSSS MCQ.

The latter specifies that the organization will respond directly to the coroner’s office regarding the follow-up of the recommendation to be applied and that a period of 90 days is allocated to inform it of the action plan that will be put in place.

“As in all situations where there is a coroner’s inquest, we carry out a complete analysis of the situation and deploy the necessary actions, when required, to improve the quality of our services,” insists Ms. Bourgeois.

In addition, the Major Crimes Investigation Division of the Sûreté du Québec conducted an investigation. No charges were filed and the file was closed.

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