Updates from the Long-Term Care Homes Public Inquiry

June 12, 2018

The Ontario Nurses’ Association (ONA) is participating in the Public Inquiry into Long-Term Care. ONA has signaled that it is participating in order to ensure that a tragedy like the Elizabeth Wettlaufer case never again occurs. ONA will post updates on the proceedings regularly.

Monday, June 18, 2018

On Monday June 18, the Inquiry heard evidence from Laura Long, who was employed as an RPN at Caressant Care Woodstock. Ms. Long described her duties as the RAI Coordinator and confirmed that residents are more complex and that at times, she was required to contact an RN for advice. Like other witnesses, she said that, generally, Elizabeth Wettlaufer was kind to residents, and would bring in food for staff and residents.

Ms. Long was aware that Elizabeth Wettlaufer did have some health issues, and knew that she was on Seroquel. She testified that she had heard once that Helen Crombez had been worried about Wettlaufer when she was changing her medications and sent the police to Ms. Wettlaufer’s home to check on her.

Ms. Long recounted an incident in which she heard Ms. Wettlaufer yelling at a resident, which she reported to the Director of Nursing. She also commented that at times, Wettlaufer was sexually inappropriate and would “hit on” students.

Ms. Long also noted that one Halloween, Ms. Wettlaufer dressed as the Grim Reaper. In cross-examination, she confirmed that this was not an appropriate costume for a party held at a long-term care home where there were palliative patients.

Following Ms. Long’s testimony, ONA brought two motions. The first was to request that several documents from ONA’s grievance files be admitted as relevant. While many documents relating to the settlement of the termination grievance had been disclosed by ONA prior to the commencement of the Inquiry, other documents had inadvertently not been disclosed. Commission Counsel and the Participating Parties discussed a process to ensure fairness so that if any questions arose from the newly disclosed documents for witnesses who had already testified, answers could be sought.

ONA’s second motion was to increase its allotment of time during the Facilities phase. ONA had been provided with five hours for the Facilities phase, which is scheduled to continue until June 28. Given the issues and questions that have arisen about the role of the union at Caressant Care, and the need for ONA to call its own witness, Jill Allingham, to testify as to the settlement of the termination grievance, ONA was concerned that it might require more time. It requested an additional 90 minutes. Counsel for Caressant Care Woodstock and Meadow Park opposed ONA’s request, while other parties, including Ontario Association of Residents' Councils and the Registered Nurses’ Association of Ontario, supported ONA’s request.

Commissioner Gillese allowed the motion and granted ONA an additional 90 minutes’ time, to be used if necessary. In so doing, she acknowledged that sometimes issues within an inquiry get more attention than anticipated – both in the inquiry and outside. The extra time allotted was to recognize that labour issues have taken on a bigger life than might have been anticipated at the start of the proceeding. She also recognized the need to ensure that a balanced perspective was presented.

The hearing is to continue June 19, 2018 with the Director of Nursing, Heather Nicholas, from Meadow Park, testifying.

Thursday, June 14, 2018

Heidi Wilmot-Smith continued to testify on June 14, saying that throughout her employment at Lifeguard, Ms. Wettlaufer worked in numerous agencies including: Revera Telfer Place in Paris; Rykka Anson Place Care Centre in Hagersville; Sienna Fox Ridge Care Community in Brantford; APANs Park Lane Terrace Long-Term Care Center in Paris; Diversicare Hardy Terrace Care Community in Brantford; Revera Briarwood Gardens in Brantford; and Delrose Retirement Residence in Delhi.

During this time, Ms. Wettlaufer attempted to murder a resident in Telfer Place.

There were a variety of issues through her short employment there and three (3) facilities refused to have Ms. Wettlaufer return: Telfer Place, Anson Place and Delrose. Lifeguard made no attempts to end Ms. Wettlaufer’s employment.

On September 7, 2016, Ms. Wettlaufer resigned from Lifeguard effective immediately, citing her inability to practice as an RN. Lifeguard did not report this to the College of Nurses.

Ms. Wilmot-Smith then engaged in a very heated cross-examination by the lawyer representing Revera. The lawyer denied much of the testimony offered by Ms. Wilmot-Smith.

The contract between Lifeguard and Telfer Place dated August 14, 2015 was not signed by Lifeguard.

Revera raised issues with Lifeguard’s orientation process. There was a formal complaint on October 24, 2015 when Ms. Wettlaufer missed her shift completely. Ms. Wettlaufer was drinking that evening, later admitting to Ms. Wilmot-Smith that she had returned to Alcoholics Anonymous. This was not reported to Revera nor the College of Nurses even after she missed a second shift in late December.

Through the cross-examination, it was learned that Heidi Wilmot-Smith – despite sending employees into many long-term care homes – had never read the Long Term Care Homes Act and/or the regulation, nor was she familiar with the requirements of the College of Nurses for employers of RNs and RPNs. Wilmot-Smith admitted she did not know that RNs must have personal liability insurance.

When cross-examined by ONA, the Inquiry heard that Ms. Wettlaufer was paid $36/hour plus statutory payment while the agency billed the agency $65/hour and 8.5 hours for an eight-hour shift. Ms. Wilmot-Smith’s testimony seems to indicate that she viewed Ms. Wettlaufer as an opportunity to “sell” the work of her agency to Caressant Care. This was not successful.

Through ONA’s cross-examination, the Inquiry also learned that Ms. Wilmot-Smith hired Ms. Wettlaufer based only on two verbal references, not the written reference from Caressant Care. Her agency, Lifeguard, did not critically evaluate her application which falsely stated Ms. Wettlaufer’s number of years of RN experience.

ONA member, Agatha Krawczyk, an RN from Caressant Care Woodstock, was the next witness.

She has been employed at Caressant Care since 2003, and testified that, “It is very, very busy in long-term care. It is much busier than the hospital. You have no time for yourself from the first minute that you get there until you leave. I can't take my breaks. No day is the same. Residents have falls, there are families to deal with etc. The day goes by fast.”

Ms. Krawczyk testified to some of the medication practices in the home.

She was the RN who reported the final medication error made by Ms. Wettlaufer that ultimately resulted in her termination, acting very professionally and demonstrating strong leadership in a very difficult situation.

She testified that “Elizabeth Wettlaufer was very friendly with the PSWs. But, in my opinion, there should be limits. You can be nice and friendly but there is a limit.”

Ms. Krawczyk concluded her testimony by saying, “Well, for me, it is still a shock, and I still can't believe it. But I have to say one thing: You know, because of this one person, you know, it doesn't mean that all Caressant Care and all registered staff are – it's so unfair. I have to say I am proud of – that I'm working for Caressant Care as an RN, and I really am telling everybody that Caressant Care is a beautiful home. It is. We have very caring staff. And I don't agree with what I'm reading in the paper.· We have wonderful staff, so...”

The final witness was Brenda Black, PSW. She described the normal work day/workload in Caressant Care Woodstock on the day shift.  She also described how working in a nursing home has changed over time, including the increase in the acuity of the residents.

Ms. Black testified that from her perspective, “we are not spending as much time with the residents as we should.”

Ms. Black worked with Ms.Wettlaufer when she was scheduled on the night shift. She described Ms. Wettlaufer’s behaviour as lazy. “She didn't want to get off her butt,” she said.

Ms. Black reported at least one incident of Ms. Wettlaufer’s inappropriate behavior in 2013.

She testified that the impact of Ms. Wettlaufer's actions: “When this happened, we were flipped upside down. We were locked down for 10 months. We had no new residents. We finally got to the point where we could give care. The residents that remained actually got more care during that time because the staffing was maintained at the same level.”

The Inquiry resumes Monday, June 18, 2018. The next witnesses are an RPN and then a representative of Caressant Care’s Human Resources Department.

Wednesday, June 13, 2018

Karen Routledge returned to continue her testimony on June 13. Ms. Routledge demonstrated her strong leadership and nursing knowledge, especially in the area of long-term care.

She testified that she believed that at most of the discipline meetings she attended with Ms. Wettlaufer, discipline was warranted.  She went on to say that grievances were filed for the last two disciplines – the five-day suspension and termination – in order to enable the Union to obtain more information and ensure that Ms. Wettlaufer was represented. She was not involved in the settlement because she was not the Union representative.

Ms. Routledge confirmed that Caressant Care Woodstock management had not followed the collective agreement to ensure that a Union-appointed representative was available at every discipline meeting.

As for the comments made by another employee that Elizabeth Wettlaufer had told a resident that “it was okay to die.” Ms. Routledge said she believes that the comment was only appropriate for families to say to their loved one. She did recall of  Ms. Wettlaufer being called “the angel of death.”

Ms. Routledge was asked questions about the unexpected death of Maureen Pickering and her call to the coroner’s office. It was the coroner’s decision to not to perform an autopsy.

Personal Support Worker (PSW) Wendy MacKnott was the next witness. She described the normal work day/workload in Caressant Care Woodstock on the day shift. Ms. MacKnott worked with Ms. Wettlaufer when she worked the night shift.

Ms. MacKnott described Ms. Wettlaufer as an odd duck who could be inappropriate sometimes.  She reported Ms. Wettlaufer following a resident fall and what she believed were inappropriate actions for an RN.  Elizabeth Wettlaufer got the resident back to bed by herself instead of waiting for two people and a lift and before she completed a full assessment.  Ms. Wettlaufer then burst a new hematoma with unsterile scissors.  On the same night, Ms. Wettlaufer did not follow up with an assessment on another resident who had a bleeding hand.

Ms. MacKnott also reported Ms. Wettlaufer in April 2013 after an inappropriate, bullying comment was made to a male resident.

Ms. MacKnott testified that she did not suspect Ms. Wettlaufer of causing intentional harm to the residents. “I love my job and I am proud of the work that we do, so it hurts when people say, ‘How can you work at Caressant Care?’” she said.

Ms. MacKnott noted in testimony she wished there could be more staff as everyone is so overworked they cannot give enough care and attention to the residents.

The final witness of the day was Heidi Wilmot-Smith, president and part owner of Lifeguard Homecare Inc. ("Lifeguard").  Lifeguard is a private agency that offers registered staffing support to various facilities, including long-term care homes and private residents' homes. It employs RNs, RPNs and PSWs for these purposes.

Ms. Wettlaufer applied for a position at Lifeguard by email on January 26, 2015. Her resume indicated that she had been employed with Meadow Park since 2014 with no end date. Lifeguard was in significant need of RNs with experience in long-term care. Ms. Wilmot-Smith testified that she was interested in her work experience in long-term care facilities, and did speak to Ms. Wettlaufer about her position with Caressant Care.

Ms. Wilmot-Smith testified that she did call Ms. Wettlaufer's references. Only two responded, one from the time she worked as a Support Worker and the other an ADON from Caressant Care.

After hiring Ms. Wettlaufer, she had a conversation with Carol Hepting of Caressant Care about their potential staffing needs. She thought that since Ms. Wettlaufer had previously worked at Caressant Care, she would be a good fit to be placed in that facility, since there would be no orientation required. Ms. Hepting confirmed they would not be interested in having Ms. Wettlaufer back but declined a request for any further details.  Ms. Wilmot-Smith did not question why.

Tuesday, June 12, 2018

On June 12, the cross-examination of Caressant Care’s Director of Resident Care, Helen Crombez continued. ONA counsel asked hard-hitting questions about her hiring practices, in particular with regard to Elizabeth Wettlaufer.

Noting that the test to terminate employment during the probationary period is much easier for an employer, ONA also asked why Ms. Wettlaufer successfully completed probation based on practice issues that arose during probation.

It was clear that Caressant Care's "progressive discipline" process was flawed.

Ms. Crombez admitted that ONA did not aggressively grieve Elizabeth Wettlaufer's discipline. ONA grieved: one five-day suspension that was quickly withdrawn, and another five-day suspension and her termination. A minimal settlement was achieved by ONA including a reference letter written by the Caressant Care HR staff.

Ms. Crombez confirmed in her testimony that ONA had used its Professional Practice process at Caressant Care, and that resident acuity had increased significantly over time. She testified that both more RNs and more staffing is required.

Now-retired RN, Karen Routledge, (who was also ONA's Bargaining Unit President for two years) testified on June 12 as well.

Ms. Routledge testified about the workload in the home, also saying that more RNs and higher staffing is required. She said there is duplication in paperwork that takes time away from important patient care.

At times, Ms. Routledge attended meetings as the Bargaining Unit President with Ms. Wettlaufer. No grievances were filed.

At other times, Ms. Routledge and other RNs served only as ‘witnesses’ when Ms. Wettlaufer received additional discipline and counseling. They were not ONA representatives at that time.

Ms. Routledge testified about the administration of insulin in the home during the time of Ms. Wettlaufer's actions. She admitted to being stunned and devastated when she learned of Ms. Wettlaufer's actions.

Monday, June 11, 2018

On Monday, June 11, the legal counsel for a group of victims and their families cross-examined Helen Crombez, Caressant Care’s former director of nursing.

Alex Van Kralingen questioned Ms. Crombez on Caressant Care Woodstock's failure to file reports with the Ministry of Health and Long-Term Care, as required. The inquiry heard that Caressant Care failed to report to the ministry on several occasions, including:

  1. October 2007, when a nurse charted that a resident had very low blood sugar. When the nurse called the physician, he replied that another nurse had already called and reported an insulin overdose. The patient was then sent to the hospital. Ms. Wettlaufer was working the shift when the call was made to the physician about the overdose. Although the reporting nurse filed an incident report, reporting the medication error, no report was filed with the hospital, despite the fact that the patient was hospitalized as a result of the insulin overdose. Ms. Wettlaufer was later convicted of aggravated assaulted related to this resident
  2. Caressant Care did not report the death of another resident, Mr. Silcox, to the Ministry of Health and Long-Term Care, despite his death being noted as "sudden and unexpected" and "accidental" in the report to the coroner.

Ms. Crombez also confirmed that despite the fact that Caressant Care corporate head office approved the installation of a camera in the medication room (following the theft of narcotics), it "just didn't happen."

ONA cross-examination

ONA legal counsel Kate Hughes then cross-examined Ms. Crombez. Ms. Crombez testified that she was aware that Elizabeth Wettlaufer had discussed her own significant health concerns, including the fact that she was changing her medication and having difficulty adjusting to that change. Ms. Crombez testified that she never followed up with Ms. Wettlaufer to determine whether her health issues impacted her ability to work.

The director of nursing also testified that she witnessed Ms. Wettlaufer stumble once, and was concerned that she was having what she described as an "episode;" however, she took no action other than asking the nurse whether she was okay.

Ms. Crombez also testified that she threatened to file a report to the College of Nurses of Ontario regarding Ms. Wettlaufer’s health issues, but that she never did so.

At Caressant Care, nurses filed multiple Professional Responsibility Clause forms raising concerns about workload and staffing issues in this home, particularly when they were required to work short on night shifts.

Ms. Crombez agreed that Caressant Care needed more nurses, and she estimated that each nurse was required to care for 20 patients.

Jane Meadus, speaking on behalf of the Ontario Association of Residents Councils, said that staffing the home during a night shift with two registered practical nurses was not equal to having one registered nurse.

Ms. Crombez also testified that any physical changes to the home’s environment, such as installing larger windows in the medication room, would not make any difference to the security of medications if there was no staff there to actually look into the room.

Friday, June 8, 2018

Caressant Care Director of Nursing, Helen Crombez, testified.

Ms. Crombez had been the Director of Nursing for approximately 30 years and knew Elizabeth Wettlaufer well.

Ms. Crombez testified about medication administration practices in the home, including the ordering, administration and destruction of narcotics, non-narcotic medications, and insulin.

She reviewed many of the more than 40 incidents that involved Ms. Wettlaufer, ranging from personality conflicts, odd behaviour, medication errors and practice issues.

Although Ms. Crombez repeatedly described Ms. Wettlaufer's conduct and practice as inappropriate, she said she did not impose harsher discipline, in part because Ms. Wettlaufer always took responsibility for her errors and apologized.

The Director of Nursing confirmed that neither she nor the home filed any reports to the MOHLTC to report neglect or abuse of patients because she "probably didn't think of it."

Ms. Crombez said she was not concerned about ONA.

ONA will cross-examine Ms. Crombez on June 11.

June 7, 2018

On Thursday, June 7, Caressant Care administrator Brenda Van Quaethem was cross-examined.

Under questioning by Paul Scott, counsel for some of the victims’ families, Ms. Van Quaethem confirmed that she was not comfortable with the low nurse staffing levels. She confirmed for the inquiry that even if an RN had just 10 residents to care for, they would still be busy.

Elizabeth Wettlaufer was directly responsible for 32 patients during the day and if she worked the night shift, she had responsibility for 82.

ONA counsel Kate Hughes cross-examined the administrator on a number of key issues related to the union.

Ms. Van Quaethem admitted that she never looked at Ms. Wettlaufer’s discipline file as a whole. She never reviewed any disciplines in 2007 and 2008, which was prior to her time as administrator. She also said she would only glance back at the file to see what level of discipline had been previously administered.

At no time did she ever look at Ms. Wettlaufer’s file as a whole, looking for a pattern.

Ms. Van Quaethem confirmed that she did not follow the ONA collective agreement. She was unaware that there was an 18-month sunset clause, instead assuming that it was one year, as it was in the Unifor collective agreement.

Although the administrator had indicated earlier in cross-examination to Paul Scott that had there not been a union, she might have terminated Ms. Wettlaufer earlier because of the financial cost to a settlement, she subsequently admitted that the decision to discipline and terminate an employee is a unilateral management decision.

ONA challenged her evidence that any settlement funds would come out of the Nursing and Personal Care [funding] Envelope. It is now on the record that ONA believes it comes from the "Other Accommodation" envelope, which is the envelope from which for-profit homes take their profit.

Importantly, the administrator admitted that ONA did not know about many of the issues involving Ms. Wettlaufer, that ONA was not aware of many of the disciplines and was not aware of the critical incident reports that were filed.

ONA was also not aware that narcotics were missing. In other words, the home did not share information with ONA – the home’s management held all the pieces of the Wettlaufer puzzle, and ONA did not.

June 6, 2018

The first witness was called to testify on June 6. Brenda Van Quaethem was the administrator of Caressant Care Woodstock, where the majority of Ms. Wettlaufer’s offences occurred (seven murders, two aggravated assaults and two attempted murders).

The Commission heard of Ms. Van Quaethem’s professional history – a former ‘nurses’ aid’ she testified that she had little training in her role. ONA notes that Ms. Van Quaethem’s background included little or no training in human resources and she was not a health-care professional. When asked what training Caressant Care’s corporate head office provided to her, she said none.

She confirmed that it is difficult to recruit and retain RNs to work in long-term care, and that Caressant Care was short of RNs the entire time she was administrator (2009-2016). It was noted that Ms. Wettlaufer had, at one point, worked seven shifts in a row; Van Quaethem stated that staff were required to work seven shifts in a row “a fair enough number of times” because of the home was short staffed.

She provided evidence of the fact that patient acuity has been rising and that the needs of residents were much more complex than they were in the past. Most residents are no longer independent – they are in wheelchairs or use walkers.

Ms. Van Quaethem reviewed Ms. Wettlaufer’s lengthy disciplinary history. She testified that during her seven years working at Caressant Care, she had been counseled on many occasions, had received multiple verbal and written warnings, was suspended several times and was ultimately terminated. The disciplines were imposed for a multitude of offences, including inappropriate communications and interactions with staff and residents, medication errors, and attendance issues.

Ms. Van Quaethem testified that on several occasions, the employer did not impose any discipline or counseling despite receiving complaints from staff. On those occasions, they may have spoken to Ms. Wettlaufer but did not take any action.

She testified that the decision to impose a suspension or termination needed to be vetted through Caressant Care’s Head Office.

Participating Parties will have the opportunity to cross-examine the former administrator on June 7.

June 5, 2018

The Long-Term Care Inquiry began on Tuesday, June 5, 2018 with the participating parties, including ONA, introducing themselves and indicating their interest in the proceeding.

ONA indicated that it is participating in order to ensure that a tragedy like this never occurs again. ONA noted that Elizabeth Wettlaufer’s conduct was an aberration, and that long-term care nurses are passionate and dedicated professionals who choose to work in this sector despite the many systemic challenges. These include chronic understaffing and underfunding, made more problematic at a time when resident acuity is increasing.

ONA will be advocating for systemic changes to ensure the highest level of resident care and safety.

Commission counsel briefly reviewed the facts of the crimes committed and provided details of each of the 14 victims (eight residents were murdered, there were attempted murders and two aggravated assaults). Ms. Wettlaufer’s early career was reviewed, including her brief period of employment at Geraldton District Hospital. She was terminated from the hospital for stealing medication.


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