Joshua Matchett said he felt something was not right when he was unable to speak to his father on April 11. He called half a dozen times and checked the video camera he installed at the 92-year-old’s long-term care practice. room, but his father was never visible.
In the late afternoon, Matchett, who lives in Brampton, Ontario, received a call from his brother saying that his father – Traven Matchett – had died in the bathroom of his room at Extendicare Halton Hills in Georgetown, Ontario, about 30 miles away. west of Toronto.
Anxious to see his father’s final moments, Matchett played the video from his father’s bedroom. That’s when he realized something was wrong.
From the video, Matchett said, it was clear that his father went to the bathroom at 9:51 am Eastern time.
“What really hurt was … nobody else showed up until 4:30 pm that afternoon,” he said.
The probable cause of his father’s death would later be considered fatal cardiac arrhythmia due to cardiovascular disease. But a report by an Ontario Ministry of Long-term Care inspector on the death concluded that Extendicare Halton Hills “failed to protect [Traven Matchett] negligence on the part of the team. “
The report also found that despite the team documenting that Matchett had been visited hourly that day – and even fed lunch – video evidence from the camera in his room showed that he was not actually seen for six hours.
As a result, Extendicare Halton Hills received three written notifications of non-compliance with the Ontario Long Term Care Act. The LTCHA establishes minimum safety standards that all nursing homes in the province must comply with.
Data obtained from a Investigation of the CBC Marketplace found that it is not the first time Extendicare Halton Hills has broken the law.
Between 2015 and 2019, the house received 125 written notifications for violations of the law and had 19 recurrences of the most serious violations, such as negligence and abuse. This makes it one of the 30 most violated houses in the province, according to data compiled by Marketplace.
One defender said that houses like Extendicare Halton Hills face virtually no consequences, even when they are repeatedly found in violation of LTCHA. Defenders are asking the province to take more stringent measures – such as fines or provincial charges – against houses like Extendicare Halton Hills, which have repeatedly violated provincial rules.
No one from Extendicare Halton Hills was available to speak to CBC for an interview about Traven Matchett’s care.
In a statement, Extendicare said he did not comment on circumstances about specific residents or staff, but said in part: “We regularly update our policies and procedures to reflect the advice of ministry inspectors and provide education to our team members to reflect any problems that are identified during an inspection. “
Registered resident change
Matchett said he installed a camera in his father’s room in March 2019 after the elderly man, who suffered from early dementia, repeatedly complained about someone entering his room at night.
Video footage shared with CBC News shows another resident entering the room shortly after installing the camera. Matchett’s father sits on the bed and tells the resident to leave.
As the other resident passes by, the footage shows Matchett’s father falling to the floor and hitting his head.
WATCH | Video footage of an altercation in Matchett’s room:
Matchett said his father had to be treated at the hospital because of his injuries.
“I was extremely shocked that this could happen even to someone who should be protected, who is a vulnerable individual and should be taken care of,” he said.
Matchett filed a complaint with the ministry and, as a result, an inspector concluded that the house violated nine sections of the LTCHA.
The report noted that the same resident who entered Matchett’s room was aggressive towards other residents on several occasions.
The inspector concluded that the house “was unable to guarantee that measures were taken to minimize the risk of altercations and potentially harmful interactions between [the resident] and other residents. “
The report also concluded that the house was unable to guarantee that at least one member of the on-call staff was a nurse.
Matchett said his father started to regress after the fight with the resident and would complain to the family that he was not receiving immediate care. Under his care orders, Matchett’s father was due to be checked every hour.
Images of Matchett’s room on the day he died, showing that he had not been checked in for about six hours, were sent as part of Joshua Matchett’s complaint to the Ministry of Long-Term Care.
WATCH | Video footage of Matchett’s room the day he died:
‘They obviously neglected my father’
In the inspection report that followed, the ministry found that the personal support worker “documented that they performed hourly checks, turned over and repositioned [Matchett] when video surveillance showed that staff did not verify the resident. ”
The report states that, according to Matchett’s file, he ate “76 percent” of his full lunch and snack, although he never left the bathroom after 9:51 am.
“The resident was found unanswered in the bathroom six hours later, without the team having seen or seen the resident,” the report said.
“They obviously neglected my father,” said Matchett.
“The investigator’s report says that team members said my father had lunch at 11:56 am and ‘He was happy and cheerful’ while he was doing it. And it stuck me up because you can’t be happy and cheerful if you’re out of breath.”
When a home is found to be in violation of the LTCHA, the Ministry of Long-Term Care may issue orders that the home must comply with – such as new employee training or implementing new policies – but Jane Meadus, a lawyer and institutional advocate for the Advocacy Center for the Elderly in Toronto, said these orders are not always effective.
“There is really no reason why [LTC homes] to comply, frankly, because if they don’t, the ministry just comes back and just reissues the order, “she said.
“And so, we see houses having violation after violation, order after order.”
Meadus said he would like repeat offenders to be hit by administrative fines or even prosecuted.
“We have never seen a provincial offense against a home, even in quite flagrant cases.”
She said that part of the problem is also funding, noting that long-term households do not always have the resources to respond to compliance orders. For example, when training is requested, filling in the team is an issue.
Long Term Care Minister Merrilee Fullerton declined to speak to the CBC for this story. In a statement to CBC News, the ministry said: “Repeated non-compliance is taken seriously by the ministry.”
The ministry has listed a number of tools at its disposal in cases where there are repeated instances of non-compliance.
One action the ministry can take is to refer the matter to the director of long-term care inspections, who has the power to temporarily stop admissions to a home until it follows compliance orders. The inspection branch can also bring in its own manager to oversee operations at the expense of the home.
In its statement, the ministry said that in March 2019, the director of long-term care inspections met with Extendicare Halton Hills to address non-compliance and that the house has since been subject to “greater monitoring with 11 unannounced inspections. ”
The ministry said it is currently following three compliance orders. It is not known whether these requests are related to the Matchett case.
According to the ministry’s statement, “long-term home inspections in Ontario continue to be the most stringent in Canada.”
Pushing for change
In his statement to CBC News, Extendicare said that a new management team at its Halton Hills facility “is working to prevent similar problems from occurring in the future”.
Joshua Matchett said he is not surprised by the history of violations at home and is speaking out because he wants to see a change in the way these violations are handled.
“A much brighter searchlight needs to be shone [on this issue] because I’m going to end up there, “said Matchett.
“We will all be subjected to the system eventually.”
Seven months after Traven Matchett’s death, his son said the hardest part was knowing that it took a video for him to finally understand his father’s complaints about the level of care he was receiving.
“For the past few months he has lived thinking that his children … did not believe him, that he was being neglected. I live with this every day.”