When Patti Watson left her 97-year-old mother Viola Wilson at Fellburn Care Centre on May 16, her mother looked lovely as she always did during their visits.
“Every day she dressed up nicely,” Watson said, “and, no matter what, she would be at the window waving till we were out of sight and blowing kisses.”
When Watson saw her mother again the following morning, Wilson was at Burnaby Hospital with a broken neck and a fatal deep-brain bleed – her eye and hand black and swollen.
“It was all so unexpected, so shocking,” Watson said. “From looking just lovely to black and blue and blood all over her, it was very painful.”
Her mother had sustained the massive injuries from what police and Fraser Health investigators both concluded was an unwitnessed fall.
But Watson and her brother Doug Wilson think their mother might still be alive today if the care home had had proper fall precautions in place, especially since their mother had already experienced an earlier unwitnessed fall just two days before.
The pair lodged a complaint of inadequate care with the Fraser Health Authority, but an investigation concluded that their allegations were unsubstantiated and minimum care standards as per the Residential Care Regulation had been met.
Under “additional findings,” however, the report states minimum care standards were not met for parts of the regulation dealing with fall prevention.
“There is no evidence in the documentation that there was a falls prevention care plan despite the resident having been identified as a risk for falls,” states the report, obtained by Watson and her brother through a Freedom of Information request.
Minimum care standards under the Residential Care Regulation require patients in long-term care to have: an assessment of their fall risk, a plan to prevent that person from falling and a plan for following up on any falls suffered by a person in care.
Fellburn did not have an assessment or prevention plan on the books for Wilson, according to the investigation, nor was there evidence in her file that the centre followed up on her earlier fall by monitoring her vital signs or checking her neurovital signs, as per Fraser Health guidelines for falls management.
There are a lot of things the care centre could have done to prevent their mother’s fatal fall, according to Watson and her brother – starting with her washroom access.
Ninety-seven-year-old Wilson, who used a walker, shared one room separated by curtains with three other women who all had to leave their room and cross a hallway if they needed to use the washroom.
At night – the time of Wilson’s fall – the room was also dark, with no night-lights, according to Watson.
She and her brother also said the care centre should have put precautions in place after their mother’s first fall, like fall mats, hip protectors and sheet sensors that would have alerted staff when she tried to get out of bed.
But Fraser Health told the NOW the care Wilson received on the night of her fatal fall was appropriate, and the shortcomings documented in the investigation report were essentially a matter of paperwork.
“The death of someone in our care is something we take very seriously,” said Cathy Sleiman, director of residential care and assisted living at Fraser Health. “There was an investigation into this tragedy, and we found the care our resident received following the fall was appropriate; however, the staff did not follow all components of the clinical practice guideline for falls, including properly documenting our resident’s care needs and wishes in her file.”
Sleiman said Fellburn had provided the health authority with a compliance plan to deal with the shortcomings and has even implemented some improvements suggested by Watson and her brother, including reassessing all clients who are mobile enough to make it to the washroom during the day to see if any need more help making it safely to the washroom at night.
That the care centre had acted on any of their recommendations was news to Watson and her brother, who said they hadn’t heard from the facility after meeting with health officials in July and who had to wait almost two months to see the investigation report after making a Freedom of Information request.
The pair said they decided to speak publicly about their concerns to prevent anyone else from suffering the same fate as their mother – a woman they say was so tenderhearted that she used her flyswatter to shoo flies out the door instead of killing them.
“For her life to end as violently as it did, is not right,” Watson said. “We don’t want any other elderly woman to spend the last 24 hours-plus of her life suffering because something wasn’t done that should have been done.”
