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County fined over ongoing non-compliance issues at Sunset Manor

Admissions ban remains in place with 43 beds now empty; county says plan is underway for reopening in 'near future'
2022-06-27 Sunset JO-001
Sunset Manor is a long-term care home in Collingwood operated by the County of Simcoe.

The province has fined the county for ongoing non-compliance with provincial standards at Sunset Manor. 

The County of Simcoe, as the operator of Sunset Manor Long-Term Care Home, has been fined $5,500 by the province for failing to comply with provincial requirements for medication management. 

The fine was issued with a newly published inspection report from the Ministry of Long-Term Care, which cites further non-compliance in administering medication to residents. 

The county's general manager of health and emergency services, Jane Sinclair, said the fine is a new measure under the Fixing Long-Term Care Homes Act, and is applied when any compliance order is re-issued during an inspection. 

"We will continue to work with the province to better understand these new standards and how we can work together to achieve our common goal of service excellence," said Sinclair in an emailed statement from the county's communications department.

"We welcome feedback from our provincial partners and remain committed to ensuring all efforts address noted areas for improvement."

An inspection by the Ministry of Long-Term Care completed throughout the month of May and published at the end of July included eight written notices of findings of non-compliance with Ontario regulations dealing with medication management, skin and wound care; falls prevention and management; prevention of abuse and neglect; and food, nutrition and hydration. 

The May 2022 inspections were completed by three ministry inspectors and the report resulted in one compliance order related to medication management in the home. 

The report stated there were 94 medication incidents at the home between April 2 and May 9, 2022, including two omissions, one missed dose, four missed signatures, and 87 medications given at the wrong time. 

Sunset Manor has been under a new admissions ban since June 2021; the ban was ordered by the Ministry of Long-Term Care after several reports of non-compliance dating back three years and documented in inspection reports.  

The county has challenged the admissions ban in court, alleging it was an excessive response prompted by the reports of an ex-employee who is now a provincial inspector. 

The province has countered that the ban was and is still necessary based on multiple reports by multiple inspectors before and after the ban was in place. It is the province’s position that the admissions ban would have been warranted even without any of the evidence presented by the former Sunset Manor employee.

The County of Simcoe confirmed today (Aug. 4) that 43 of the 148 beds at Sunset Manor are empty.

The medication incidents cited in the July report involved five different residents. One was given pain medication more than one hour late twice in the course of eight days according to incident reports. 

Another resident was not given the first dose of a new medication on the evening the prescription was to be started. 

One resident was given medication while being treated for a hypoglycemic event (low blood sugar) and the protocol of withholding insulin and contacting a doctor right away was not followed. 

Another resident was given medication when their blood pressure was low, despite orders to withhold the medication when the blood pressure was low. Incidents similar to this, related to insulin being given to residents with low blood sugar, were also investigated in the winter inspections and included in the report published in May. 

According to the report published in July, a resident who was supposed to get medication if their blood pressure was high did not receive that medication for five days when their blood pressure was high. 

Lastly, a resident whose medication was to be withheld if their blood pressure dropped below a certain threshold received medication on two occasions when the blood pressure was listed on the notes as “not applicable.” 

According to the ministry inspection, no incident reports were created for the blood pressure-related medication incidents. 

The inspection notes two of the Sunset Manor directors of care acknowledged the medications were not administered as prescribed. 

As a result of these medication incidents, one resident experienced pain, one required extra monitoring and three others were put at risk of negative health effects, states the inspector’s report. 

Because there was already an outstanding compliance order from inspections done in January and February related to similar issues, the ministry issued a fine of $5,500. 

The winter 2022 compliance order states the home must ensure drugs are administered according to the directions from the prescriber, and that if that does not occur, an incident report is completed. 

Inspection reports from January/February and May, 2022, indicate a history of non-compliance from the home in the area of medication administration. 

Between Dec. 31, 2021, and Jan. 24, 2022 (25 days) there were 470 medication incidents, including one wrong medication administered, two medications not administered, 19 missing signatures, one delivery incident, and 447 medications given at the wrong time. 

In the July 2022 report, the county has been given a deadline of Aug. 17, 2022 to comply with five actions in the order. Documentation to prove the actions were done must be kept at the home. 

Firstly, the county has to make sure the five residents in the latest inspection report are receiving medication according to the directions given by the prescriber by completing daily audits for two weeks. 

All staff in the Collingwood 2 home area must be given a review of the flagging/alert system in the electronic medication administration record.

Two staff identified by the ministry are to be "re-educated" on the home’s policies for management of diabetic residents and managing hypoglycemic incidents. 

The county must provide education to all registered staff in the home for the administration of medications with specific blood pressure and/or pulse rate parameters. 

The home must develop and implement an audit to make sure medications are held based on blood pressure and/or pulse rate parameters and that prescriber’s instructions are followed. 

The fine is due within 30 days. 

The latest inspection report did note the home had complied with two other previous orders related to documenting procedures and/or actions taken on residents and making sure all staff are participating in the home’s infection control program. According to the inspectors, the home has met the terms of both orders.  

Two others related to complaints of abuse were noted as "closed" in the July report. 

Sinclair, in her statement, said the home and county is pleased the May inspection resulted in the removal of four compliance orders of the five inspected in the review. 

"This significant achievement highlights the number of improvements that have been made at Sunset Manor," stated Sinclair. "We are confident that we are moving closer to achieving admissions in the near future, and our team has been developing a transition plan to quickly and seamlessly welcome new residents into the home once the cease of admissions order has been lifted." 

In an emailed statement, also sent through the county's communications staff, Warden George Cornell called the "lifting of four compliance orders" a "positive step forward." 

"County of Simcoe Council is extremely supportive of Sunset Manor and all our long-term care and seniors' services delivered across the region," stated Cornell. "County council is closely monitoring the situation and continues to provide input and guidance as the home works to achieve full compliance." 

The County of Simcoe operates four long-term care homes in Simcoe County, including Sunset Manor, Simcoe Manor (Beeton), Georgian Manor (Penetanguishene), and Trillium Manor (Orillia). 

You can read the most recent inspection report by the Ministry of Long-Term Care on Sunset Manor here.