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From YouTube: Audit Committee - April 30, 2018
Description
Audit Committee meeting – April 30, 2018 – Audio Stream
Agenda and background materials can be found at http://www.ottawa.ca/agendas.
A
A
A
Can
we
confirm
the
confidential
minutes
of
that
30th
of
November
2017
the
they've
been
distributed
to
you
in
an
envelope?
Please
ensure
that
you
return
these
envelopes
to
the
coordinator
by
the
end
of
the
meeting
the
if
you'd
like
to
wait
to
the
end
of
the
meeting
to
approve
the
minutes
or
we
can
confirm
them
now.
It's
your
choice,
everybody's
good,
okay,
confirmed.
Thank
you
item
number.
One
of
the
agenda
is
the
reports
on
investigations
in
the
long-term
care
homes.
A
B
Mr.
president,
at
on
juquila
documented
procedures,
una
parte
de
Sierra
Club,
a
jujube
hood
Katerina
Titus
apostle
is
okay
too
many
Donny
fajitas
went
alone.
Jury,
therefore,
be
it
resolved
that
the
audit
committee
approved
the
addition
of
this
document
for
consideration
by
the
committee
at
today's
meeting
pursuant
to
section
89
3,
the
procedures
by
law
by
law,
2016
377
is.
C
C
Good
morning
mr.
chair
members
of
the
Audit
Committee
councillors,
I'd
like
to
introduce,
in
this
center
or
administrative
assistant
on
my
left
and
Sonia
Brennan,
a
deputy
Auditor
General
on
my
right
they'll,
both
be
helping
with
the
presentation
today:
Mr
Lopez,
Adelle,
Norman
Malcolm,
also
vectors
ed,
memoir,
AO
shield.
We
certain
repeal
Solana
wasallam
in
a
municipality
in
municipality,
apron
or
May
and
verificar
general.
C
C
C
There
are
three
types
of
audits
that
are
carried
on
by
this
office.
There
are
financial
audits,
there
are
performance
or
value-for-money
audits
and
compliance
audits.
The
other
responsibilities
for
this
office
is
the
administration
of
the
fraud
and
waste
hotline
and,
of
course,
we
carried
out
any
investigations
that
come
from
the
fraud
and
waste
hotline
they
do
to
poor
ordered
week,
so
they
rizzuto
they
do
no,
no
responsibility.
C
Miserable
fat
days
are
kept
apparel,
a
single
model
indirectly
OSI
news
of
all
Fateh
in
their
vacacion
telephone
conformity,
avec
la
la
politique,
a
processor.
These
two
reports
today
are
related
to
two
of
our
functions.
The
first
is
that
we
performed
a
couple
of
investigations
that
came
out
of
reports
to
the
fraud
and
waste
hotline
and
also
our
role
as
compliance.
Auditor
is
the
city
in
compliance
with
legislation,
specifically
the
long
term,
long
term
care
homes,
act
and
also
our
own
policies
and
procedures.
C
C
We'll
begin
with
the
review
medication
management
so
examine
at
MNA
or
apples
or
problems
in
la
la
Lin,
direct
late,
olavo
or
coma,
say
a
litlle.
Do
melody
set
tell
castle
and
Tudor
a
lot.
The
Rwanda
director
I
ate
a
loss,
a
poly
minister
to
the
salting.
It
is
one
day
long
generator,
Ontario
port
or
they
cut
for
you
didn't
administer
a
palpable
like
Simon,
Ave
port
bill,
the
determine
a
seal,
a
for
you
or
the
practic.
They
procedure,
a
Des
Moines
and
the
control
adequate
for
our
system,
digestion
the
Medicare
month.
C
Our
the
front
waist
line
received
a
couple
of
reports
in
2017.
We
began
our
work
in
the
summer
of
2017
and
you
recall
the
chart.
Certainly
after
we
began
that
work,
the
Ministry
issued
a
director
or
director
referral
order
for
three
of
the
four
city
of
long
City
of
Ottawa
long
term
care
homes.
Accordingly,
we
delayed
our
work
until
January
2018.
C
We
spent
we
made
a
significant
investment
into
this
investigation
in
addition
to
interviews
and
documentation
review
the
other
team
spent
more
than
five
days
at
each
home,
conducting
direct
observation
of
personnel
during
the
performance
of
their
tasks
in
relation
to
medication
management.
Now,
at
this
point,
mr.
chair
I'd
like
to
thank
staff
for
their
cooperation
and
quite
popular
candid
comments.
It
made
our
work
a
lot
easier
and
the
cooperation
was
was
certainly
appreciated.
C
Know
please
applaud
poster
session,
but
exult
iliad
a
lickin,
Dali
politically
procedure
or
comparison
Beckley.
A
vaguely
mo
de
lengua
for
the
very
sea
level
at
on
conformity,
avec
la
loire
per
exam
for
a
dois
of
warren
system
entered
listener,
digestion
the
medical
director
ethic
as
a
limiting
value.
Tilly
zero
for
you
drove
a
turkey
desert
platter.
A
author
posed
a
administrate
that
we
eliminate
the
vessel
regulars.
C
Under
the
long-term
care
homes
act,
a
long-term
care
home
must
have
an
interdisciplinary
medication
management
system
and
that
that
system
must
include
the
accurate
acquisition,
receipt,
dispensing
storage,
administration
and
destruction
and
disposal
medication.
A
lot
of
them
may
seem
logical
to
all
of
us.
It's
no
different
than
than
any
activity,
but
in
this
case,
you're
you're
dealing
with
medication-
and
they
must
be
the
system's-
must
be
more
rigorous
than
you
would
see.
C
In
any
other
instance,
with
any
other
type
of
inventory,
the
homes
must
have
comprehensive
policies
and
procedures
that
not
only
documented,
they
must
be
clearly
understood
to
meet
the
requirements
of
the
regulation.
The
staff
involved
have
to
be
accredited
to
carry
out
their
duties
and
there
must
be
an
interdisciplinary
team
that
meets
at
least
quarterly,
that
evaluates
the
effectiveness
of
the
homes
medication
management
system.
We
found
some
gaps
in
the
city's
policy
and
procedures
when
we
compared
them
to
the
regulations.
C
You
may
not
be
aware,
but
the
pharmacy
service
provider
conducts
quality
improvement,
reviews
reviewed
a
sample
and
noted
that
there
were
recurring
findings
and
that
there
was
nothing
to
show
that
corrective
actions
were
implemented,
which
the
regulation
requires
for
the
most
part
other
than
the
lack
of
enforcement
of
some
of
the
policies
and
procedures.
We
found
that
the
policy
procedures
that
did
exist
were
adequate
but
as
as
we've
stated,
they
must
be
followed.
C
Well,
can
summer
like
position
a
reception
or
the
medic
Emma,
the
free
do
I
have
worked
the
Moyer,
the
controller
she's
they
she
saw
that
command
a
the
reception
of
the
medical
for
the
personnel.
After
is
a
new
servo
coaster.
They
could
lay
the
suit
delivery,
is
also
soon
seen.
A
pallet
personnel
may
Lily
visit
eight
days.
Initially
the
signature,
the
new
Carmel
part
the
theremin,
a
seal,
a
signifier.
It
isn't
this
employee
a
authorized,
a.
D
Thank
you
with
respect
to
acquisition
and
receipt
of
medication.
The
Act
requires
that
that
all
drugs
receive
for
use
that
long-term
care
homes
are
required
based
on
resident
usage.
The
Act
also
requires
that
the
controls
in
place
to
govern
the
ordering
and
receipt
of
drugs
by
authorized
personnel
only
and
that
there's
a
fully
maintained
and
detailed
drug
record
in
place
for
drug
receipt.
This
usually
happens
on
the
evening
shift,
but
the
verification
process
so
checking
the
receipt
against
the
the
items
received
is
not
done
at
that
time.
D
It's
done
later
in
the
evening
on
the
night
shift,
we
did
look
at
the
records
and
found
that
some
discrepancies
do
occur.
Ideally,
the
drug
should
be
verified
at
the
time
of
receipt.
This
ensures
that
any
discrepancies
are
communicated
on
a
timely
basis
to
the
pharmacy
rather
than
having
been
signed
as
received,
and
then
dealing
with
discrepancies
later
on
drug
receipts
are
signed
by
staff,
but
we
couldn't
determine
whether
or
not
those
staff
were
were
authorized
because
the
the
initials
or
signatures
were
illegible.
D
There's
a
master
signature
list,
that's
kept,
but
we
couldn't
match
the
the
signatures
or
initials
to
that
list.
With
respect
to
safeguarding
we
observed
that
drugs,
the
drug
deliveries
were
left
unattended
at
an
open
location.
While
the
pharmacy
representative
made
deliveries
to
the
units
we
also
observed
drugs
left
at
a
second
unsecured
location.
D
While
the
rep
went
to
locate
the
nurse
to
take
custody
of
the
drugs,
the
packages
should
be
placed
in
a
secure
location
at
all
times
upon
receipt,
and
this
is
important,
as
we
were
spending
time
in
these
homes
there
busy
places
there
our
staff
there
are
visitors.
There
are
volunteers,
there
are
vendors,
so
there's
a
lot
of
people
that
are
that
are
in
the
homes
and
it's
important
that
the
drugs
are
secured
at
all
times
and
in
in
compliance
with
the
regulation
as
well.
D
D
With
respect
to
the
storage
of
medications,
the
Act
requires
that
controls
are
in
place
to
ensure
that
all
controlled
and
non
controlled
drugs
are
stored
and
safeguarded
and
accessible
only
to
authorized
individuals.
They
need
to
have
adequate
procedures
in
place
to
reconcile
control,
drug
inventories,
monthly
and
identify
discrepancies
on
a
timely
basis.
The
homes
are
also
required
to
ensure
that
drugs
that
are
stored
are
secured
and
locked
at
all
times
when
not
in
use
and
access
to
these
areas
must
be
restricted.
D
D
Each
home
also
has
a
government
pharmacy.
This
provides
access
to
non
prescription
drugs
in
bulk
quantities.
The
government
pharmacies
are
in
areas
that
are
separate
from
other
medication
storage
areas.
At
both
homes.
We
found
no
adequate
systems
in
place
to
document
the
acquisition,
the
removal
or
the
use
of
those
drugs.
There
was
no
physical
stock
taking
or
reconciliation
done,
to
identify
if
there
are
any
differences
between
the
quantities
on
hand
versus
what
was
dispensed.
This
allows
the
opportunity
for
unauthorized
removal
without
notice
or
accountability,
and
it
increases
the
risk
of
drug
diversion.
D
D
We
observe
the
home's
practices
to
determine
whether
or
not
they
when
keeping
with
the
regulation,
as
well
as
the
city's
policies
and
procedures.
This
included
the
examination
of
the
medical
administration
records
they're,
also
referred
to
as
marce
Ammar,
is
a
record
of
all
medications
prescribed
to
each
resident.
The
pharmacy
provider
produces
these.
D
These
forms
for
the
homes
there
is
one
mark
per
resident
and
we
can
see
them
in
binders
where
the
nurses
are
when
they're
carrying
out
the
administration
of
medication,
when
the
nurse
administers
the
medication
to
the
resident
they're
responsible
to
initial
the
mark
to
to
show
evidence
that
this
occurred.
So
one
of
the
requirements
is
for
authorized
individuals
to
be
administering
the
medication
based
on
a
review
and
similar
to
the
the
similar
finding.
D
We
were
unable
to
determine
the
the
initials
or
the
signatures
matched
the
master
signature
list,
so
we
couldn't
tell
for
certain
whether
or
not
it
was
an
authorized
staff
member
that
was
administering
the
drugs.
Why
is
this
a
problem?
Should
there
be
any
issues
with
respect
to
drug
administration?
It
allows
the
city
provide
evidence
that
an
authorized
employee
did
perform
that
activity.
D
We
also
examined
how
it
was
ensured
that
the
right
resident
receives
the
right
medication.
I
just
want
to
read
a
small
excerpt
from
the
city's
policies
on
this,
and
it
says
if
unable
to
self-identify,
look
at
the
resident
picture
in
the
Mahr,
so
the
Marr
form
has
a
photo
of
the
resident
and
verify
with
bracelet
or
armband.
D
However,
for
the
residents
who
were
nonverbal,
they
were
not
identified
using
a
second
form
of
identification,
the
the
bracelet,
even
though
they
didn't
respond
to
their
names
and
oftentimes.
They
were
in
a
forward
position
where
they
were
slouching,
so
it
wasn't
easy
to
see
to
see
their
faces
and
match
it
with
a
photo.
D
We
also
noticed
in
several
instances,
residents
who
were
not
wearing
the
bracelets
or
armbands.
So,
although
the
staff
has
good
familiarity
with
the
residents,
there's
also
significant
amount
of
staff
turnover,
and
this
would
impact
the
risk
of
errors
in
the
situation
when
we
reviewed
the
documentation
to
look
for
sign
off
of
the
medications
being
administered,
we
found
that
in
some
instances-
and
it
was
a
very
small
amount-
that
there
was
no
notation
to
indicate
that
the
drug
had
been
administered,
we
cost
checked
the
instances
that
we
found
against
the
resident
records
to
see.
D
If
there
was
an
incident
or
hospitalization,
there
was
a
cause
that
would
explain
the
the
medication
not
being
administered.
We
did
not
find
causes
in
those
situations.
We
did
notice
that
the
nurses
were
frequently
interrupted
during
medication
rounds,
which,
which
could
be
a
factor
in
the
records
not
being
updated.
D
With
respect
to
the
destruction
and
disposal
of
drugs
at
long-term
care
homes,
the
Act
requires
that
each
home
has
a
drug
destruction
and
disposal
system
to
identify
and
destroy
and
dispose
of
drugs
that
meet
the
criteria
for
destruction,
so
it
would
be
items
that
are
expired,
discharged,
discontinued,
etc
and
on
an
annual
basis.
Each
homes
system
is
audited
for
adherence
and
effectiveness
and
the
results
are
documented,
and
this
is
right
from
the
the
long-term
care
homes
Act.
D
We
found
that
non
control
drugs
are
not
destroyed
according
to
the
city's
policies
and
procedures.
The
policy
states
that
at
the
time
of
disposal
the
drugs
the
medication
must
be
removed
from
its
packaging
with
a
second
team
member
and
the
surplus
medication
should
be
placed
in
a
tamper-proof
disposable
bin
supplied,
and
that's
the
photo
that
you
see
here.
Those
are
the
bins
and
you
can
see
the
medication
is
still
in
its
packaging.
D
As
well,
the
regulation
requires
that
all
drugs
are
destroyed
in
teens,
based
on
our
interviews
with
personnel.
After
the
drugs
have
been
identified
for
destruction,
one
nurse
takes
the
drugs
to
the
destruction
bins,
so
it's
not
done
in
teams
all
the
way
to
the
to
the
end
of
the
process.
Again,
this
increases
the
risk
of
drug
diversion
as
well.
We
noticed
the
bins
with
the
non
controlled
substances
they're
removed
from
the
medication
rooms
and
they're
placed
in
a
designated
storage
area.
D
Then
they're
moved
to
an
unsecured
holding
area
to
await
pickup
by
a
third
party
contractor
depending
on
the
schedule.
The
bins
can
be
there
for
a
number
of
days
before
pickup
and
the
holding
areas
are
used
by
other
service
providers.
Once
again,
this
is
another
area
where
the
drugs
are
unsecured
and
there's
a
risk
for
diversion.
C
To
Lee
for
a
result,
the
medic
mo
control
a
in
no
control
8c,
necessarily
a
lo
Cascio,
the
resident
adverse
weather
in
medica
mark
in
the
pepper,
normal
mode
party.
The
solar,
a
genetic
Amato
doc,
also
called
subtle,
reserve
reserve
the
medic
amount
or
casuals
examine
revelaed
is
anomaly:
dollar
casino,
CEO
of
register
lameta
chemically
due
for
a
certain
car.
Renovating,
not
a
poor,
justify
a
low-rated
genetic
Emma.
C
The
daughter
occur
usable
releve
desire,
mathematic
dollar
killed,
who
they
medica,
Medicare,
more
arrests
of
OC,
okay,
okay,
avatar
pal,
about
a
periodic
to
stop
the
medical
Madonna
Reserve.
Now
it
a
real
real,
easy
Ilkley
rapprochement,
a
effective
way,
Lamarque
activate
the
more
in
the
control
at
acquire,
repeal
a
risk.
C
The
detour
Molly
medic
Emma
the
direction
early,
decor
avec,
took
notice
at
the
recommendatio
every
home
has
an
emergency
drug
supply
in
case
of
resident
has
a
need
for
medication
outside
of
their
normal
medication
regime,
for
to
ensure
that
the
the
home
was
in
conformity
with
the
regulation.
We
look
to
ensure
that
only
approved
drugs
were
maintained
in
the
emergency
drug
supply
that
the
supply
was
clearly
located.
Labeled
secured
tracked
and
documented
at
all
times,
to
prevent
unauthorized
access
and
distribution
of
drugs.
A
medication
log
is
maintained
of
each
drug
in
the
emergency
drug
supply.
C
Each
time
a
drug
is
removed
from
the
emergency
drug
supply,
the
resident
for
whom
it
was
removed
should
be
documented
and
an
emergency
replacement
form
completed
and
faxed
to
the
pharmacy
to
replenish
the
supply
for
that
particular
drug.
In
our
review
of
the
logs,
we
found
inaccuracies
in
the
record-keeping
for
the
drugs
at
both
homes.
In
some
examples,
there
was
no
documentation
to
support
the
purpose
for
the
removal
of
the
drugs
from
inventory.
C
C
We
also
found
that
there
was
no
periodic
stock
taking
of
the
drugs
in
the
supply,
nor
was
there
any
reconciliation.
Unfortunately,
the
lack
of
adequate
controls
currently
in
place
makes
the
risk
of
drug
diversion
very
high.
Each
drug
in
emergency
drug
supply
also
has
an
approved
maximum
quantity
of
drugs
that
should
be
held
at
any
particular
time.
We
found
that
whether
record
reflected
drug
quantities,
we
found
in
the
record
that
there
were
some
instances
where
the
drug
quantities
on
hand
exceeded
that
maximum
quantity.
C
C
No
recommendatio
a
the
road
all
cackle,
a
lolicon
dollar
spared
a
procedure
at
a
relay
disk.
The
de
Toulon
among
American
male,
a
puta
Sheila
des
identify
a
in
conclusion.
Mr.
chair,
we
found
that
that
the
city
needs
to
strengthen
controls
over
the
management
of
medication
in
long-term
care
homes,
to
address
the
issues
found
with
current
practices.
C
They
must
do
this
in
order
to
reduce
the
risk
of
drug
diversion
and
improve
the
long-term
care
homes
practices.
Although
the
existing
policies
and
procedures
are
adequate
to
guide
the
functions
in
relation
to
getting
medication
management,
they're
not
being
followed
in
a
number
of
areas.
Within
the
key
cycles
of
the
medication
management
system,
we
noted
numerous
deficiencies
in
the
long-term
care
homes,
practices
that
increase
the
risk
of
drug
diversion
specifically
related
to
the
storage,
destruction
and
disposal
of
drugs
with
the
emergency
drug
supply.
A
A
You're
gonna
do
like
they're
asked
okay
all
right.
Why
don't
we
take
a
pause
on
the
report
here
and
ask
some
questions
on
what
you
just
brought
forward
so
counselor
Ellis
interior,
first
anybody,
Thank
You
mr.
chair
and
thank
you
mr.
Hughes,
and
your
team
interested
in
the
medication.
Mr.
Hugh,
when
you
talk
about
the
management
of
the
medication,
so
it
leave
it
open
to
many
speculation.
A
Either
disappearance,
EFT
or
or
being
given
to
patient
without
proper
record,
can
explain
a
little
bit
more
like
what
could
but
I
understand
could
be
many
area
and
I'm
surprised
to
hear
from
you
there's
no
cameras
in
those
facilities
because
there's
cameras
surely
to
God
everywhere,
except
in
the
bathrooms
these
days.
So
how
could
a
facility
like
this
doesn't
have
a
camera
to
find
out
how
the
medication
been
allocated.
C
So
that
includes
its
movement,
its
initial
storage
within
the
long-term
care
home,
its
movement
to
the
to
the
unit,
the
area
where
it
would
be
used
and
the
controls
well,
it's
in
storage
and
then
the
controls
after
it's
designated
for
destruction,
for
example,
and
what
we
found
was
that
that
the
processes
and
policies
that
are
in
place
are
in
conformity
with
the
legislation.
But
a
lot
of
the
procedures
are
not
being
followed.
C
There's
no
one
checking
to
ensure
that
checking
on
a
regular
basis
to
ensure
that
all
of
the
procedures
are
followed
and
when
that
happens,
that
means
that
medication
could
be
lost
or
could
be,
could
be
stolen
and
without
without
things
like
stock
taking
and
reconciliations
you're.
Not
even
aware
that
medications
are
missing,
you
don't
know,
you
also
don't
know
when
they
when
they
could
have
gone
missing
and
that's
that's
a
concern
and
then,
of
course,
there
are
other.
There
are
other
things
that
could
be
done
to
improve
the
protection
over
the
medication.
A
Don't
understand
and
I
heard
what
you
said:
there's
a
there's
a
control
management
in
place,
but
it's
not
been
follow,
I,
think,
that's
even
worse,
so
we
already
have
to
measure
and
plays,
but
if
they're
not
been
followed,
that's
not
sure
you
know
where's
management
role
here,
not
making
sure
the
policy
been
follow
on
in
those
area
and
I
still
need
to
understand
a
question
about
the
camera.
Why
there
is
no
camera
and
those
facilities
when.
C
You
introduce
a
system
of
control,
it's
imperative
that
the
people
first
of
all
be
familiar
with
it.
They
understand
it
and
that,
on
a
regular
basis,
steps
are
being
taken
to
ensure
that
that
that
management
is
checking
to
ensure
that
staff
are
following
those
those
procedures
and
when
staff
knows
that
that
people
are
following
those
procedures.
First
of
all,
they'll
be
reminded
to
follow
them,
and
in
the
rare
case
where
you
have
an
individual
who
will
help
themselves
to
something
that
they're
not
entitled
to.
C
If
they're
aware
that
there
or
there
is
an
opportunity
to
remove
something
without
without
without
anyone's
knowledge,
they
will
avail
themselves
of
that
opportunity.
So
it
is.
It
is
imperative
that
the
systems
that
are
in
place,
which
are
well
designed
that
that
they
be
followed
and
that
the
checks
be
done
on
regular
basis
to
ensure
that
they
are
being
followed.
E
The
the
recommend
date,
one
of
the
recommendations
from
the
Auditor
General-
is
to
put
cameras
in
those
rooms,
and
we
will
absolutely
review
that
that,
in
terms
of
putting
cameras
to
ensure
that
there
is
no
diversion
of
any
of
the
prescriptions
and
medications
at
this
point,
we
do
not
have
them.
We
have
them
in
hallways
and
in
some
of
the
residence
rooms
at
the
request
of
the
families,
but
not
in
those
rooms,
but
we
will
be
considering
them
going
forward.
B
Thank
You,
chair
Hubli
and
just
following
up
on
counter
else
on
Terry's
question
about
cameras,
he's
referring
to
recommendation,
10
and
and
management's
response
is
a
risk
cost-benefit
analysis.
We
will
be
completed
by
q2
2019,
that's
a
year
from
now.
It's
it's
a
it's
an
important
issue.
I
share
counselor
else
on
Terry's
concern
what
why
can't
that
be
acted
on?
Why
can't
we
not
have
that
that
analysis
done
more
quickly.
There.
E
We
have
received
feedback
from
five
different
sources
since
July
of
last
year,
and
CPS
will
receive
later
today,
consolidated
work
plan
that
we
flex
all
of
those
recommendations
and
it's
upwards
of
80
different
recommendations.
What
we're
doing
is
trying
to
prioritize
those
that
are
more
closely
related
to
the
care
and
services
of
our
residents
and
families
as
a
priority
and
looking
at
those
other
recommendations,
some
of
which
came
out
of
the
the
two
audits
that
you'll
hear
about
this
morning.
E
If
we
can
move
forward
on
these,
we
certainly
will,
and
when
we
talk
about
some
of
the
diversion
we
in
terms
of
missing
medication
there,
there
we
do
find
that
we
may
miss
a
dose,
those
that
when
they
go
missing,
we
actually
record
those
and
so
in
terms
of
risk.
At
this
point
it
is
low,
but
we
can
certainly
look
at
moving
it
forward.
Based
on
any
recommendation
we
receive
from
committee
I.
B
Think
if
we
look
at
the
the
whole
gamut
of
recommendations,
it's
it's
an
inventory
control
issue
and
I
guess
I'm
addressing
management.
Now
it's
an
inventory
control
issue.
It's
not
that
complex!
It's
a
pretty
dangerous
substance.
What
type
of
drugs
are
I
guess
to
the
auditor-general
order
to
Janice
what
type
of
drugs
are
we
talking
about?
Can
you
can
you
give
us
some
of
the
names
or
their
class?
Mr.
C
Chair
there
are
too
low
management,
can
correct
me
if
I'm
wrong.
There
are
two
classes
controlled
and
non
controlled,
and
then
the
controlled
ones
would
include
opioids,
for
example,
pain,
medication,
and
then
there
are
the
non
control
drugs
and
there
are
two
sister
two
policies
for
disposal
of
each
of
those
types
of
drugs.
Recommendations
that
the
observations
that
we
made
on
the
destruction
and
disposal
of
drugs
related
to
the
non
control
drugs
which,
although
not
opioids,
still
have
a
value
and
still
have
consequences
for
if
they
were
misused,
for
example.
So.
C
B
So
back
to
management,
where
dangerous
substances
that
have
a
market
value
danger
to
patients
a
danger
to
staff
danger
of
theft.
It's
an
inventory
control
issue
and
I'm,
just
looking
at
management's
responses
to
to
the
recommendations
Q
to
2019
Q
to
2019
q1
2019,
q2
2018,
and
it
seems
to
me
that
it's
and
I
recognize
the
complexity
in
the
layers
of
it.
E
Going
back
to
the
question
about
the
different
types
of
medication,
the
medication
that
goes
into
the
sealed,
bins
or
over-the-counter
medications
such
as
tylenol
Modi
and
those
types
of
things
they
should
be
removed
from
their
packages
put
in
the
bin
and
with
water
added.
The
other
medications
go
into
a
lock
box
with
two
individuals,
two
authorized
individuals
that
we
view
that
and
track
that,
and
then
it
goes
into
that
lock
box
until
returned.
So
there's
quite
a
bit
of
rigor,
I
think
around
the
policies
and
the
procedures.
Currently.
B
C
B
E
E
F
B
And
they
have
and
I'll
just
wrap
up
mr.
chair
and
note
that
there
are
others
who
have
questions
and
have
you
found
mr.
Artur
general,
that,
in
your
opinion,
the
application
of
the
policies
and
procedures
which
you
say
are
appropriate
are
being
are
being
enforced,
are
being
exercised
in
compliance
with
the
professional
standards
of
of
that
profession.
C
C
From
our
point
of
view,
the
consisten
around
medication,
the
policies
and
procedures
are,
for
the
most
part,
adequate.
There
are
a
couple
of
gaps
that
have
to
be
addressed,
but
what
we
are
most
concerned
about
are
the
the
procedures
that
are
not
being
followed
and
there
is
no
enforcement
and
there
isn't
there's
no
checking
up.
That
is
being
done
to
ensure
that
that
those
procedures
being
followed-
and
there
is
no
follow-up
when
somebody
doesn't
follow
those
procedures
and
I'm
most
concerned
about
the
emergency.
B
A
C
Mr.
chair,
the
counselor
through
you
to
the
counselor
that
the
counselor
is
is
quite
correct.
I
spoke
to
that
individual
at
length.
As
you
all
know,
and
it
was
the
concerns
expressed
by
him
and
others
that
initially
led
to
this
investigation,
and
we
looked
at
all
aspects
of
the
of
the
system
as
as
is
evidenced
by
the
the
issues
that
that
we
found
the
difficulty
and
I
think
you'll.
Probably
you'll,
probably
see
some
of
the
some
of
our
findings
later.
C
That
would
that
would
likely
address
some
of
the
issues
that
were
raised
by
by
that
gentleman
and
others
that
we
spoke
to,
and
that
is
in
relation
to
the
dispensing
of
medication
at
the
appropriate
time
for
the
appropriate
resident
and
you'll
see
later
that
staff
had
expressed
concerns
about
about
the
activities
that
they
have
to
do
and
in
the
in
the
time
that's
available
to
it.
And
it's
it's
clear
that
that
affects
the
timing
of
the
delivery
of
the
medication.
C
What
we
were
not
able
to
determine
adequately
to
the
level
that
we
do
in
an
audit
was
if
that
is
a
large
problem.
But
it's
certainly
something
that
I
think
should
be
looked
at
and
I
believe
falls
under
the
domain
of
the
running
of
the
of
the
home
itself
and
I
I
think
the
report
that
will
be
delivered
to
the
committee
afterwards
we'll
address
some
of
those
issues.
Thank
you.
G
Recognized
some
of
the
issues
that
are
coming
up
because
I
have
to
take
medications.
It
happens
when
we
get
older.
They
issue
that
I
think
you
raised
the
point
that
on
our
staff,
could
be
an
issue
and
is
really
I.
Think
is
there's
a
couple
of
things
they
get
the
crux
of
this
matter,
first
of
all
a
few
years
ago
and
all
we
were
forcing
efficiencies
on
every
department,
including
long
term
care,
and
they
had
some
reduction
in
their
budgets.
G
Because
of
that-
and
it
seems
to
me
that
the
efficiencies
here
are
not
saving
time
but
making
better
controls.
Did
you
see
any
indication
that
the
problem
is
really
related?
The
facts
and
you've
mentioned
it
a
bit
that
they
literally
do
not
have
the
time
sometimes
to
follow
all
of
the
instructions
that
are
part
of
the
protocol
in
order
to
actually
get
the
basic
work
done.
There.
C
Certainly,
mr.
chair,
that
was
a
sentiment
that
was
expressed
to
us
by
staff
and
we'll
talk
about
it
shortly.
But
when
we
talk
about
the
the
lack
of
enforcement
of
key
steps
in
the
system
and
control
of
medication
that
that
enforcement
would
come
from
the
supervisors
and
management,
the
you
know
the
very
the
checking
from
time
to
time.
We're
not
it's.
C
It's
the
the
checks
that
that
should
be
done
to
make
sure
that
that
people
are
recording,
as
they
withdraw
medications
from
an
inventory
that
it's
for
a
valid
patient
and
that
the
mathematical
calculation
is
accurate
and
that
the
inventory
that's
on
that.
That
is
on
hand
is,
is
the
white
inventory,
but
generally
those
are
things
that
that
that
would
not
be
done
by
the
the
the.
C
G
Maybe
that,
then,
should
go
to
staff
as
I
really
was
interested
in
I
know,
because
of
turnover.
There
has
to
be
ongoing
training
all
of
the
time,
because
there's
a
lot
of
regulations
with
these
these
homes
that
people
have
to
be
aware
of,
and
the
not
just
the
ones
that
have
the
right
to
sign
things,
but
the
other
staff
need
to
understand,
there's
no,
who
can
do
what
as
well.
G
This
was
wondering
what's
happening
with
the
training
program,
doing
it
not
just
for
the
frontline
workers,
but
also
for
the
managers
are
supposed
to
deep
checking
on
this,
to
that's
sure
that
they
are
fully
aware,
because
I
think
that
you
do
get
busy
in
your
jobs,
we
find
it
even
in
our
jobs.
Then
you
put
things
aside
because
you're
too
busy
to
get
to
them
and
I
think
that
there's
some
sort
of
prioritization
of
things
that
needs
to
go
on-
and
this
was
running-
we've
only
had
senior.
G
These
are
homes
for
what,
but
six
or
seven
years
now,
I
guess
since
they're
taken
over
from
the
province
or
the
regulations
change
anyway.
So
what
do
we
have
in
place
to
do?
This
and
do
you
have
adequate
budgets
to
actually
implement
all
of
these
controls
and
if
not,
how
are
you
going
to
deal
with
that
aspect?
There's
two
questions.
There.
F
Mr.
chair,
on
all
of
our
staff
on
higher
output
through
an
orientation
program
that
would
support
the
practices
and
procedures
relating
to
medication.
In
addition
to
that,
every
four
years
we
go
through
accreditation,
Canada
and
in
2016
our
medication
review
of
119
standards.
We
were
98%
compliant
with
the
accreditation
standards
for
medication.
In
addition
to
that,
we
also
do
through
the
Institute
of
safe
medical
practices.
We
do
a
survey
of
all
of
our
homes
on
an
annual
basis
and
then
those
quality
improvement
opportunities
are
built
into
to
our
medication
program.
G
Well,
there's
one
thing
to
get
an
orientation
when
you
start
but
I've
been
through
those
with
other
groups,
and
you
get
bombarded
with
a
lot
of
information
before
you've
actually
been
in
doing
it.
Do
you
have
like,
after
a
couple
of
months,
it's
really
very
useful
to
then
have
every
review
going
over,
because
at
that
point
they
see
things
happening.
They
know
how
it
works
a
lot
better
and
they
can
actually
understand
things
better
because
it
tends
to
you
know
what
it's
like
when
you're
being
trained.
G
F
Mr.
chair,
we
do
have
peer
support
within
our
registered
nurse
and
complement.
So
when
a
new
nurse
starts
with
us,
we
will
buddy
them
up
with
another
nurse
and
they
would
be
there
to
support
one
another,
often
as
well.
On
the
day
shift.
We
would
have
a
registered
practical
nurse
and
an
RN
working
together.
So
is
there
about
support
between
the
two
in
terms
of
ensuring
the
medication
practices
are
being
followed?
I
would
like
to
add
one
other
point
in
relation
to
the
recommendations
and
the
delay
and
some
of
the
recommendations
moving
forward.
F
We
are
negotiations
for
a
new
resident
care
information
system
which
will
be
implemented
in
the
fourth
quarter
of
this
year.
As
a
second
phase
to
that
IT
plan,
we
will
be
going
forward
with
an
electric
medication
administration
record
which
will
address
several
of
the
recommendations
that
have
come
forward
in
today's
are.
F
Mr.
chair,
we
also
work
very
closely
with
our
pharmacy
provider,
who
actually
develops
the
policy
procedures
in
conjunction
with
us,
and
we
will
be
working
very
closely
with
our
pharmacy
provider
to
address
the
areas
that
are
being
recommended.
We
take
these
very
seriously
and
we've
already
started
to
take
actions
in
terms
of
the
receipt
of
the
medications
when
they
arrive
in
the
homes
of
being
put
under
lock
and
key
immediately
until
a
registered.
Stop
can
pick
up
those
medications
and
take
them
to
her
unit
with.
G
That
person
from
the
pharmacy
then
ensure
that
the
person
signing
for
them
is
one
of
the
authorized
people
and
that
the
medication
I
think
was
said
to
us
counted
or
checked
at
that
time
to
see
that
it
was
what
was
ordered
was
what
received,
because
that
was
one
of
the
pitch
issues.
I
think
I
just
heard
raised
earlier.
G
F
F
F
Currently
our
practice
is
to
work
with
pharmacy
provider
and
what
we're
doing
now
is
we
are
going
to
have
the
driver
when
he
arrives,
we
will
notify
the
charge
nurse
in
the
building
and
that
driver
will
then
deliver
the
medications
to
the
Chargers
in
the
building
so
that
we
won't
have
them
being
stored
at
the
reception
area
until
a
register
staff
member
is
able
to
pick
them
up.
What's.
G
F
So
the
receiving
of
the
medications
for
the
nurse
to
go
through
all
of
those
are
very
time-consuming
and
would
have
an
impact,
a
direct
impact
on
the
care
and
services
to
residents.
We
are
doing
the
checking
on
the
night
shift
where
there's
time
for
the
nurse
to
be
able
to
validate
the
medications
are
correct
and
any
discrepancies
are
reported
immediately
to
the
pharmacy
and
those
discrepancies
are
corrected
right
away.
So.
G
You
have
that
arrangement
with
the
pharmacy.
They
take
your
word
for
it
then
I
know
if
that's.
The
problem
of
course
is
of
course,
that
these
are
busy
places
with
patients
that
need
a
lot
of
attention
normally
and
the
I
can
see
where
the
difficulties
could
come
in
so
but
I
do
think.
The
ongoing
training
is
actually
crucial,
not
just
for
once
the
city
runs,
but
everyone
in
the
province.
Frankly,
so
thank
you.
A
Thank
you.
Capsule
welcome
to
council
Jerusalem
Thank
You
mr.
chair
I.
Think
councillor
Wilkinson
asked
a
lots
of
good
question,
but
it
is
really
sad
and
disturbing
to
read
some
of
the
finding
on
the
other,
the
report,
because
when
people
put
their
parents
or
loved
on
at
home,
it's
the
main
things
is
because
for
us
to
give
them
a
long,
don't
care
which
those
medications
come
first
and
in
the
finding
and
all
these
dis
management
receiving
and
dispersing
and
all
that
I'm
glad
to
hear
management.
A
Excuse
me
I'm
glad
to
hear
the
management
are
taking
steps
right
away
and
because
you
know
these
are
very
important,
key
finding
and
I
hope
we're
not
going
to
wait
for
another
two
three
months
to
do.
Another
follow-up,
but
I
encourage
the
senior
management
to
really
look
at
this
very
seriously,
because
really
the
drugs
are
important
for
our
for
our
resident
I
sit
on
a
I
sits
on
a
board
of
the
director
for
the
long-term
care
and
hospital
care
center.
Most
of
you
know
de
and
our
main
and
our
stream.
A
The
most
important
things
is
to
look
after
the
drugs.
How
we,
how
we
administer
the
drugs,
how
we
receive
them
and
we
dispose
them
I?
Don't
it's
really
sad
to
see
that
we
had
to
wait
for
an
audit
report
to
find
this
finding
so
I
hope
that
these
or
all
these
mistakes
will
be
look
seriously
at
them
and
don't
wait
in
the
timeframe.
We
need
to
address
them
right
away.
My
other
question
would
be
probably
to
the
mr.
to
the
AG,
but
do
we
have
a
price
tag
about
all
these
mismanagement?
C
Mr.
chair
I
can't
say
that
we
we
did
not.
We
did
not
cost
out
the
the
potential
losses
if
anything
was
divert
and
the
medications
were
diverted
but
and
we
did
not
cost
what
the
extra
controls
would
be.
This
was
an
investigation
around
medication
management
and
we've
identified
the
problems
and
the
solution
rests
with
management,
but
at
the
end
of
the
day,
the
policies
and
procedures
that
have
been
written
for
the
most
part
adequate.
The
question
is
the
enforcement
to
make
sure
that
staff
are
follow
our
doing
what
what
the
policies
and
procedures
say.
A
A
Thank
you.
Kelso
truce,
counselor
cutter.
Thank
you
very
much
mr.
chair
and
thank
you
very
much
mr.
Hughes,
for
your
audit
this
morning.
Just
a
couple
things.
Mr.
Hughes
I
mean
we
work,
till
audits
from
your
office
and
our
previous
auditor
on
a
regular
basis
and
majority
of
the
audits
that
I
see
sitting
on
this
table
seems
to
suggest
a
lack
of
check
and
balances.
You
mentioned
this
morning
that
you
see
the
policies
in
place,
yet
it's
not
being
followed
or
there's
a
lack
of
follow-through.
A
As
an
auditor,
do
you
ever
recommend
to
the
city
staff
as
to
how
to
not
only
improve
the
checks
and
balances
that
are
currently
in
place,
but
how
to
go
beyond
that
step
in
terms
of
carrying
forward
to
avoid
audits
like
this,
where
you
know
the
biggest
thing
I
see
here,
is
the
lack
of
checks
and
balances
that
in
the
policies
of
their
staff,
is
there
yet
there's
no
follow-up
in
terms
of
either
receiving
these
drugs
and/or
handing
them
off
to
an
appropriate
person
and/or
to
administer
them
properly?
So
just
your.
C
Comments
on
that,
mr.
auditor,
mr.
chair,
through
you
to
the
counselor
I,
think
a
prudent
manager
looks
at
all
of
the
activities
under
the
responsibility
and
identifies
the
areas
of
risk
and
knowing
where
the
areas
of
risk
are
for,
of
course,
in
this
instance
its
inpatient
care,
and
it
would
be
in
medication
as
well.
And
when
you
look
at
medication,
where
are
the
rests
and
the
risks
are
going
to
be
things
like
over
medicating
under
medicating,
not
medicating
and
and
then
the
controller
of
the
medication
itself.
C
We
do
not
know,
but
we
do
know,
for
example,
that
the
validation
of
the
withdrawals
and
the
verification
of
the
inventories
from
from
from
time
to
time
are
not
happening
now,
and
the
question
that
that
a
prudent
manager
must
ask
is
where
should
I
be
ensuring
that
my
staff
are
performing
certain
functions
to
protect
the
residents
and
to
protect
the
organization
and
and
ensure
that
the
organization
is
in
compliance
with
the
legislation?
It's
it's
a
it's
a
question
that
a
prudent
manager
on
a
regular
basis
must
ask
themselves
so.
A
Thank
you
for
that.
Just
coming
back
again
to
that
point,
when
you
mentioned
the
manager,
the
supervisor
on
duty
Oh
at
that
time
should
be,
you
know,
acting
on
those
items
going,
you
know
into
making
sure
that
their
procedures
are
followed.
Have
you
or
your
people
when
you
go
and
do
those
audits
ever
recommend
it
to
the
on-site
staff
at
all
about
those
suggestions
or
those
comments
that
you
have
or
that
you're
going
to
report
on
to
say,
look,
here's
something
worth
slagging.
So
you
must
follow
this.
A
C
Chair
when
we,
when
we
go
and
then
I
I,
will
tell
you
that
I
have
visited
busily
at
the
home
as
well
and
I've
been
I've,
seen
how
busy
they
are
and
I've
seen
how
dedicated
their
staff
are.
There's
there's
no
question
that
the
staff
that
the
staff
are
not
dedicated,
I
think
everyone
has
commented
how
busy
they
are.
When
we
talk
to
the
staff,
we
ask
the
staff
to
provide
us
with
all
of
the
policies
and
procedures
and
where
they're
located,
for
example,
and
it's
there,
we
received
them
from
the
staff
and
from
management.
C
A
F
A
Of
my
colleagues
talked
about
cameras
a
little
while
ago,
and
why
don't
we
have
cameras,
so
was
a
costing
done
of
the
necessary
funding
to
implement
the
gaps
or
the
tweaks
or
the
cameras
because
seems
to
me
that's
where
the
cost
issue
is
based
on
what
you're
saying
all
the
way
pieces
are
there
they're
just
not
being
followed,
and
how
do
we
follow
them?
And
technology
is
one
of
the
ways
we
can
do
it
through
cameras
and
whatnot.
So
as
it
could
be
yourself,
it
could
be
staff.
C
Mr.
chair,
no,
we
did
not
do
a
costing
through
to
the
counselor,
but
cameras.
Don't
cameras,
don't
make
sure
people
do
what
they're
supposed
to
do.
They
provide
another
another
benefit,
but
the
I
have
I
have
come
here
in
the
past,
with
audits,
where
there
are
no
policies
and
procedures,
and
our
recommendation
is
to
put
policies
and
procedures
in
place.
In
this
instance,
there
are
policies
and
procedures
that
are,
for
the
most
part,
as
you
put
it.
A
little
bit
of
tweaking
would
improve
those
policies
and
would
improve
those
procedures.
C
A
E
Is
a
mr.
chair:
there
is
a
report
that's
going
to
fedko
tomorrow,
actually,
and
within
that
report
there
is
a
recommendation
to
establish
1
million
dollars
to
set
aside
for
things
such
as
technology
training
and
some
equipment
that
needs
to
be
changed,
such
as
beds
and
lists,
and
those
sorts
of
things.
So
out
of
that
funding.
It's
something
we
should
can
certainly
look
at,
and
that
was
what
we
identified
in
our
recommendation
back
to
the
Auditor
General
about
reviewing
the
the
costs
and
risks
associated
with
putting
in
the
cameras
into
the
and
into
these
rooms.
E
A
Of
the
things
we
seem
to
have
heard
is
there
should
be
more
than
one
staff
doing
this,
and
there's
only
one
stop
doing
it.
This
might
be
better
done
during
the
day,
but
we're
doing
it
at
night
because
it's
less
busy
at
night.
So
if
some
of
the
answer
to
this
a
change
in
how
we
stop
or
how
any
staff
we
have
is
that
part
of
the
solution
that
would
make
the
existing
policies
and
procedures
work
better.
E
So
that's
a
that
is
a
two-fold
question
and
just
in
terms
of
the
front
end
question
mr.
chair
is
that
we
have,
through
all
of
our
consultations
and
through
all
of
the
reviews
that
we
have.
The
one
consistent
message
is
that
we
need
more
staff.
So
absolutely
that
will
assist
us
going
forward
and
there
will
be
more
information
coming
forward
at
CPS
following
this.
This
meeting
today,
at
this
point,
I'll
just
turn
it
over
to
to
Dean
to
talk
a
little
bit
about
the
staff
that
do
the
authorized
staff
for
medication.
F
Mr.
chair,
so
the
staff
that
are
authorized
to
receive
at
administered
medication
are
all
licensed
or
the
registered
nurse
registered
practical
nurses.
They
by
law
are
bound
to
the
policies
and
procedures
relating
to
the
administration
of
medication,
the
reconciliation
of
the
medications
on
the
night
shift.
We
have
not
had
any
issues
where
a
residents,
health
or
safety
was
put
at
risk
because
we
chose
to
do
the
the
cross
check
of
the
medications
on
the
night
shift.
A
C
Chair
the
reason
why
we
raise
it
is
the
risk
is
not
to
the
resident.
The
risk
is
that
medication
could
go
stray
before
it's
reconciled
and
well
it's
it's
wonderful
that
the
pharmacy
provider
will
make
up
any
deficiencies.
That
just
means
that
that
we
have
facilitated
the
possibility
of
medication
going
astray
before
we
do
the
reconciliation,
that's
what
the
that's!
What
the
recommendation
is
is
directly.
It
has
nothing
to
do
with
residents
missing
medication.
It
has
nothing
to
do
with
the
city
having
to
pay
extra
for
medication
that
might
go
astray.
C
A
Thank
you.
Gums
are
going
to
come
to
the
lab
all
security
Thank
You
mr.
chair
and
I
like
to
go
back
to
what
I
have
some
staff
about
their
response
to
to
the
camera.
So
if
there's
a
cameras
in
the
hallway
and
camera
system
in
the
building,
why
this
one
to
added
to
the
medicine
room
will
take
almost
another
year
to
get
installed
by
a
I
need
to
understand
this.
Why
especially
we're
tomorrow's
going
to
be
air
funding
allocated
to
that
area?
F
A
So
you're
telling
me
we
don't
have
to
wait
till
first
quarter
of
2019
to
install
cameras
in
a
medicine
room.
That's
correct!
Okay,
thank
you.
Thank
you.
Carroll
Center
II
just
want
to
point
something
out,
but
there's
a
lot
of
questions
here
and
we're
just
through
the
first
part
of
the
report
and
I
think
it
needs
to
be
said
that
typically
the
mr.
Auditor
General
you
touched
on
it
earlier.
A
Usually
you
come
to
committee
with
recommendations
to
enact
a
new
policy
or
modify
a
policy
and
often
what
we're
dealing
with
here
is
finances
and
and
dollars,
and
cent
issues.
This
is
different.
The
this
report
today
is
about
my
parents
in
long-term
care.
It's
about
your
parents
that
can
go
to
long-term
care
or
your
grandparents.
So
that's
a
dealing
with
people
issues
today
and
so
I
really
appreciate
that
my
colleagues
had
a
lot
of
questions
on
this
report,
because
some
of
these
findings
were
troubling
I.
A
Think
it's
great
to
see
that
management
recognizes
what
needed
to
be
done
here
and
has
a
path
forward.
There's
questions-
and
this
is
where
I'll
put
my
question
in
I.
Just
don't
understand
when
it's
something
as
simple
as
we
can't
read
the
signature
that
something
can't
be
done
right
away
to
address,
that
can
employees
not
be
given
a
number
that
they
would
sign
with
that
number
that
you
could
recognize,
or
could
you
ask
them
to
print
their
last
name
so
that
you
would
know
who's
touching
that
medication?
F
So
mr.
chair,
the
medication
administration
record,
the
forms
that
are
being
used
and
provided
by
the
pharmacy
are
standard
for
industry.
They
are
very
tiny
in
terms
of
where
are
the
staff
member
can
put
their
initials?
That's
why
we
have
a
master
list
of
all
of
the
employer
who
are
licensed
to
provide
medications
with
their
initials,
their
signature,
their
employee
number,
so
that
we
can
act.
We
can
have
an
independent
review
to
validate
who's
administered.
Those
medications.
C
A
C
Mr.
chair
should
also
point
out
that
in
some
instances
the
Masters,
the
master
list
of
signatures
has
exactly
that
signatures
and
yet,
in
the
the
medical
record,
they're
showing
and
initials.
So
you
you,
you
can't
even
when
you
do
have
a
complete
list
of
signatures,
if
somebody's
using
their
initials
they're
still
illegible.
Okay,.
A
Thank
you,
my
sorry,
general
I
think
what
we'll
do
here.
I'd
like
to
move
on
to
the
second
part
of
your
report,
perhaps
I
could
say,
vice-chair
evolved.
Oh
one
last
question
I'd
like
to
offer
you
or
ask
the
chair
Dean's,
to
perhaps
take
that
on
my
third
committee
to
try
to
figure
out
a
way
that
they
can
track
the
medication
that
you
yourself
would
be
able
to
know
who
signed
it
is
that
there.
Thank
you,
okay,
sir.
Just.
B
Two
quick
get
one
comment
and
a
one
more
question:
let's
remember,
the
objective
is
not
to
to
to
the
signatures.
The
objective
is
to
know
to
have
control
on
the
supply
of
drugs.
That's
the
objective
so
that
there
is
a
a
master
list,
but
that
the
it's
not
being
reconciled
does
not
does
not
attain
the
objective
on
April
13th,
we
received
a
follow-up
from
Kevin
Wiley
and
from
Dan
Chaney.
B
With
respect
to
two
audits
that
this
committee
had
undertaken
that
the
Auditor
General
had
undertaken
in
November
giving
us
an
update,
can
I
ask
management
whether
in
four
months
we
could
get
an
update
as
to
the
recommendations
of
the
implementation
of
the
recommendations
that
we
are
finding
in
the
Auditor
General's
report
today
in
four
or
five
months,
as
as
other
departments
have
done.
Mr.
E
A
C
Wellif
Edelin
a
passel,
a
bureau,
the
verification,
general
error'
suit
leopard
and
then
in
present
our
days,
a
Lagasse
on
the
practic,
the
gestural
duties
relative
out
and
in
acid
out
the
veal
or
sexual
on
to
the
do
resi
doe
a
cure,
a
Leo
London
or
for
a
new
servo
autumn,
le
travel,
CVP
passive,
equal
astral,
interrogate
a
lenticular
Daytona
fellatio
Loserville
in
Telugu,
a
locket
I'll
examine
the
recession,
the
vector
the
the
Alexa
mental
gesture,
automatic
Emma,
Liberty
locket
it
a
sward,
FMS.
Well,
the
conquer.
C
May
this
allegation
present
a
doll,
a
letter,
consumer
there's
action.
The
administrator.
The
administration
now
kept
protest
relief
at
on
to
around
a
measure.
Please
pol
administratio
on
a
post
Alessi
down.
There
is
on
travel
on
a
team
na
or
play
this
employee,
actually
Darcy
unemployed.
For
you,
new
0,
a
2
J
or
see
legislation,
a
OSI
layer,
regular
mo
and
see
Kelly
politic
a
procedure.
The
level
concern
a
letter
poured
acid
on
la
viola,
sexual
news,
/,
oç
analyze
a
lead!
Does
he
médico
de
reza?
Don't
they
report
the
car?
C
There's
a
logical
analogy:
get
the
gab
letter
poured
acid
out
in
town
a
ocx
them
later
poured
a
special
team
in
Estelle
le
curry
eldest
employee.
A
late
last
year,
the
office
of
the
Auditor
General
received
two
anonymous
letters
regarding
allegations
of
questionable
management
practices
in
response
to
an
incident
of
alleged
resident
to
resident
sexual
abuse
of
the
City
of
Ottawa
long-term
care
home.
We
began
our
work
as
quickly
as
possible
and
to
ensure
the
integrity
of
the
evidence.
C
We
incorporated
this
work
with
the
medication
management
review
that
we
just
presented
the
information
we
receive
purported
that
management
did
not
respond
to
the
incident
appropriately.
The
objective
our
investigation
was
to
refute
or
validate
the
allegations
and
concerns
raised
in
the
letters.
In
relation
to
management's
actions,
we
gathered
evidence
in
relation
to
management's
response
to
the
incident
to
determine
whether
they
complied
with
the
long-term
care
homes,
Act,
the
respective
regulation
and
the
city's
policies
and
procedures.
In
the
course
of
this
investigation,
we
conducted
interviews
with
certain
current
and
former
staff
members
of
the
home.
C
Accordingly,
we
interviewed
the
registered
nurse,
the
registered
professional
nurse
and
the
personal
support
workers,
both
those
on
shift
and
those
on
subsequent
shifts,
the
on-call
manager,
the
program
manager
of
resident
care
and
the
program
manager
of
personal
care.
We
reviewed
the
legislation,
of
course,
the
long-term
care
homes
Act
and
the
regulation
and
the
city's
policies
and
procedures
related
to
incident
reporting
and
sexual
abuse.
C
We
examined
the
health
records
for
residents
involved
the
shift
reports,
the
on-call
logs,
the
incident
reports,
both
internal
and
external,
the
ministry,
inspection
reports
and
selected
employee
mails
once
again,
I
have
to
state
that
staff
were
Altman
cooperative
now.
I
must
say
that
some
of
what
you
will
hear
will
be
disturbing
and
I
apologize,
but
this
level
of
detail
is
important
to
understand
both
the
incident
and
the
problems
that
we've
identified
with
the
response
to
the
incident
or
plate.
C
Aljahmeir
says
in
the
res
either
M&A
assertion
in
the
resident
attained:
the
demos,
coffee,
Nate
info,
tallulah,
Laura's,
IDO,
Ave,
manifested
comfort,
more
sexual,
inappropriate,
a
dirty
pre-spawn
de
la
journée,
Ella
personal
Levy
Cassini
on
our
top
dollar
employee
at
the
Kuvera.
The
resident
complete
Monday
essay
on
the
supposition,
a
solar
resident,
complete
Marva
to
a
you,
CA
se
Aziz,
the
Sofitel
ruler,
laughs,
I'm,
a
I
get
a
a
a
communique
avec
leur
Justin
a
of
the
gap
poorly.
For
me,
the
Lucido,
a
savoir
silica
la
cadaver,
a
to
the
scene
la
la
this.
D
On
an
evening
shift
last
year
at
a
long-term
care
home,
a
full-time
personal
support
worker
I'll
refer
to
this
individual
as
thee
as
the
lead.
Psw
was
working
on
the
floor
that
night
with
a
casual,
PSW
and
casual
workers,
someone
who's,
not
a
full-time
employee
and
they
they
fill
in
for
the
the
permanent
full-time
staff.
D
They
were
working
on
the
transfer
of
residents
to
the
rooms
that
takes
place
after
supper.
The
lead
PSW
was
checking
both
sides
of
the
house
because
the
casual
worker
didn't
know
where
to
put
the
residents
during
this
time.
The
lead
PSW
asked
the
casual
PSW
about
a
female
resident.
They
didn't
see
because
it
was
time
to
put
the
residents
to
bed.
The
lead
PSW
went
to
check
for
her
and
he
didn't
find
her.
The
female
resident
is
confined
to
a
wheelchair
and
she
was
nonverbal
at
that
point.
D
The
lead
PSW
ran
to
one
of
the
male
residents
rooms
because
they
had
a
feeling.
The
lead
PSW
stated
that
they
had
been
briefed
about
a
male
resident
exhibiting
sexual
behaviors
when
they
had
started
working
on
that
floor
on
two
separate
occasions.
Earlier
that
same
day,
the
male
resident
had
been
reported
to
be
demonstrating,
inappropriate
sexual
behaviors.
We
verified
that
this
was
documented
by
staff.
D
D
The
lead
PSW
immediately
contacted
the
casual
PSW
for
assistance
and
instructed
his
coworker
to
get
the
RPN
on
staff.
The
PSW
instructed
the
male
resident
to
put
on
his
clothes
and
stayed
with
the
residents
in
the
room,
the
aapki
unattended
to
the
scene
of
the
incident
and
then
left
to
notify
the
RN
the
charge
nurse
on
duty,
while
the
lead
PSW
and
the
RPN
were
in
the
male
residence
room.
The
male
resident
made
sexual
comments
and
demonstrated
sexual
behaviors
the
charge
nurse
attended
to
the
male
residents
room
and
was
provided
with
full
information.
D
D
D
D
D
D
So
we
created
this
table
and
I
apologize.
It's
not
easy
to
read
and
that's
part
of
the
issue
on
the
first
column,
you'll
see
the
city's
policy
on
critical
the
critical
incident
system,
and
this
is
essentially
a
policy
on
reporting
requirements
in
the
second
column,
it's
the
abuse
policy
in
the
city
and
then
in
the
third
column,
the
long-term
care
home
regulation-
and
we
just
took
small
aspects
of
these
that
demonstrate
one
of
the
inconsistencies.
The
confusion
is
the
first
column
you'll
see
that
it
talks
about
when
to
notify
for
for
an
incident
of
abuse.
D
The
first
two,
the
first
one
mentions
injury-
that
there
must
be
injury
for
reporting.
The
second
to
the
policy
and
the
regulation
do
not
mention
injury
in
the
second
row.
There's
guidance
for
calling
the
police
again.
The
first
column
indicates
injury,
but
neither
the
abuse
policy
nor
the
regulation
mention
injury
as
a
requirement
for
immediate
reporting.
D
Finally,
in
the
last
row,
specifically
relating
to
the
a
single
policy,
the
reporting
policy
and
one
section
it
states,
all
alleged,
suspected
or
witnessed,
incidents
of
abuse
will
be
reported
to
police
in
another
area
that
same
policy
again,
it
mentions
injury
in
relation
to
abuse.
So,
as
you
can
see,
it's
difficult
to
understand
the
guidance
and
this
causes
a
problem
for
staff.
D
A
stated
earlier
staff
did
not
immediately
report
the
incident
to
the
ministry
in
the
police
based
on
understanding
the
facts
of
the
incident.
Immediate
reporting
should
have
taken
place.
Notification
was
done
the
following
day.
This
action
was
in
response
to
the
second
charge
nurse
that
came
on
duty
the
next
morning
enquiring
and
following
up
on
the
matter
with
the
call
manager
had
this
person
come
in
and
not
revisited
the
decision
that
was
made
the
night
before
this
incident
would
have
gone
unreported
to
both
the
ministry
and
police.
D
We
examine
the
communication
and
the
accompanying
documentation
between
the
RN
the
charge
nurse
on
duty
and
the
con
call
manager
on
that
shift.
We
found
differences
in
this
information
in
an
interview
the
charge
recalls
that
certain
detailed
information
was
provided
to
the
on-call
manager.
We
noted
that
her
description
of
the
incident,
as
well
as
the
reporting
in
the
system
was
consistent,
was
also
consistent
with
information
that
we
obtained
from
other
staff,
and
our
interviews,
interview
with
the
on-call
manager,
stated
that
these
additional
details
were
not
provided
or
reported
on
the
night
of
the
incident.
D
Uncle
managers
maintain
a
log
of
information,
so
every
time
they
receive
a
call
there
to
document
the
details
of
that
information,
we
found
that
the
the
details
that
were
recorded
by
the
charge
nurse
in
the
system
that
night
were
not
consistent
with
what
was
reported
in
the
on
call
log.
There
was
much
much
less
information
in
that
log.
D
Furthermore,
despite
the
uncle's
man
managers
belief
that
they
received
inadequate
information
to
make
an
informed
decision,
there
was
no
follow-up
conducted
by
that
manager
with
the
nurse
regarding
this
matter.
It
would
have
been
a
good
practice
to
prevent,
reoccurrence
and
ensure
future
compliance
with
reporting
requirements.
D
D
Based
on
these
facts,
in
the
absence
of
close
supervision,
the
male
resident
posed
a
known
risk
to
the
other
residents
of
the
unit.
Stronger
safety
measures
were
only
implemented
after
the
incident
occurred,
and
this
was
in
the
form
of
providing
one-on-one
monitoring
of
the
resident
and
eventually
the
resident
was
transferred
to
an
all-male
unit
in
the
home.
D
D
C
Excuse
me,
mr.
chair
another
finding
was
that
the
perception
of
staff
is
that
management
at
the
home
does
not
consistently
respond
to
concerns
on
a
timely
basis.
During
our
investigation,
we
conducted
several
interviews
with
staff
who
held
different
roles
within
the
home
on
or
around
the
time
of,
the
incident.
A
recurring
issue
noted
by
the
interviewees
is
that
there's
a
perception
that
management
does
not
always
respond
to
concerns
on
a
timely
basis.
C
We
also
filed
a
lack
of
awareness
of
the
fraud
and
waste
hotline.
The
city's
employee
code
of
conduct
requires
employees
to
disclose
breaches
of
the
code
of
conduct
or
other
city
policies.
This
matter,
the
matter
can
be
reported
to
their
manager,
the
city
solicitor,
the
city
manager
or
the
Auditor
General.
A
majority
of
the
interviewees
were
not
aware
of
the
Auditor
General's
hotline.
Employees
who
were
aware
did
not
know
that
it
could
be
used
to
report
concerns
with
respect
to
non-compliance
of
the
city's
practices
or
non-financial
questions
or
non-financial
questionable
matters.
C
In
interview,
some
employees
said
they
may
have
reported
concerns
anonymously
through
the
hotline
for
the
most
part
staff.
We
spoke
to
felt
comfortable,
raising
issues
with
the
direct
supervisors
about
workplace
issues,
although
there
is
a
reluctance
to
raise
concerns
they
may
have
had
about
their
own
managers.
Now.
Mr.
chair
I
must
say:
there's
been
much
discussion
at
previous
audit
committees
about
the
need
to
revitalize
the
fraud
and
waste
hotline.
They
need
to
promote
the
hotline.
C
During
our
investigation,
we
identified
over
200
relevant
when
I
say
relevant.
They
actually
talked
about
this
particular
incident
200
relevant
emails,
but
there
may
have
been
more,
but
unfortunately
we
were
only
able
to
obtain
22
of
these
backup.
Emails
are
overwritten
every
three
months
which
limits
our
ability
to
recover
possible
evidence
related
to
any
matters
under
investigation
without
sufficient
evidence.
The
city
may
not
be
able
to
take
the
appropriate
actions
and
including
per
sium
pursuing
are
seeking
recoveries
to
protect
the
city's
incidents.
A
recovering
rate
of
only
10%
was
quite
disturbing
on
our
part.
C
Ikuo
conclusion,
support
received
after
day
Kennebec
initial,
also
on
global
avenir,
can
assess
your
Protege
Lavoisier
elected
respect,
a
legislation.
In
conclusion,
mr.
chair
no
assurance,
we
have
absolutely
no
assurance
that
should
a
similar
assurance.
A
similar
incident
occur
in
the
future
that
would
be
handled
appropriately
to
protect
the
resident
and
comply
with
the
legislation,
and
that
concludes
our
presentation.
Mr.
chair.
A
H
Mr.
chair,
thank
you
and
thank
you
to
the
the
auto
general
for
for
his
findings
and
his
work
on
these
two
files.
I'm.
The
only
comment
I'll
make
is
that
and
I
realize
there'll
be
questions
on
this
incident,
which
will
flush
this
one
out
more
fully.
The
few
comments
I
want
to
is
that
long-term
care,
because
of
the
issues
here
and
as
we're
seeing
provincially
and
nationally
is
under
a
great
deal
of
scrutiny.
Mr.
H
fur
share
I'll
be
here
at
CPS
committee
later
this
morning
as
an
independent
third-party
review,
the
other
General
has
just
conducted
two
investigations:
the
result
of
fraud,
waste
hotlines,
the
Ministry
of
Health
and
long-term
care
has
been
in
the
homes.
In
fact,
they
were
all
three
in
the
homes.
At
the
same
time,
we
have
a
multitude
of
recommendations
that
we
received
from
the
Auditor
from
mr.
H
Fujairah,
which
you'll
see
and
from
the
ministry,
which
have
been
incorporated
into
a
comprehensive
action
plan
that
is
going
to
be
action
and
people
are
going
to
be
assigned
to
action.
These
things,
some
of
the
timelines
I
know,
council
members
have
raised
the
timeline.
Some
of
the
timelines
were
actually
state
as
they
were
because
the
audit
recommendations
were
done
before
we
have
the
action
plan
completed
around
the
finances
and
some
of
the
other
recommendations
and
motions
which
will
be
presented
at
the
cps
committee
in
that
fedko.
So
there's
been
developments
ongoing
developments.
H
This
isn't
going
in
terms
of
in
terms
of
improving
and
making
the
implement,
creating
the
implementation.
The
momentum
to
correct
these
actions-
you
will
see
that
and
the
other
as
acknowledges
that
staffing
is
a
is
a
significant
issue
in
terms
of
the
ability
of
our
staff
to
be
able
to
complete
all
the
expectations
that
we
have
on
them.
H
That
management
is
is
endorsing
the
as
far
as
the
incidents,
the
medication
management,
the
abuse
incident.
You
know
I
think
the
other
general
has
been
a
and
through
the
questions
and
answers
from
the
first
one
I
think
you
flushed
out
the
the
key
issues
around
Mis
around
this
I
want
to
say
that
you
know
the
open
the
potential
on
the
on
the
medication
management
of
you
know
something
going
missing
and
something
happening
is
there
because
of
the
gaps.
However,
the
findings
didn't
show
that
anything
actually
went
missing.
H
We
don't
know
that
they
did
or
not,
and
that's
part
of
the
problem
and
I
think
we
have
to
tighten
that
up,
but
I
want
to
share
counsel,
also
that
that
the
other
general
also
found
that
the
drugs
administered
do
correspond
to
prescriptions.
The
people's
prescriptions
and
sometimes
in
states,
do
happen.
They
happen
in
hospitals
that
happen.
H
Long-Term,
cares
and
I'm
not
trying
to
excuse
it,
but
I
think
that
the
findings
here
and
the
recommendations
are
very
good
for
us
in
terms
of
tighten
those
things
up
and
ensuring
that
we
don't
have
any
ability
to
create
a
perception
that
these
things
aren't
happening.
The
abuse
incident
to
hear
more
about
what
happened.
What
happened
on
this
one?
It's
it's
heartbreaking
to
hear
that
these
things,
this
incident
has
happened.
It's
heartbreaking
to
hear-
and
you
will
hear
from
mr.
H
free
share-
that
patient
a
patient
abuse
is
something
that
does
occur
in
long-term
care
homes,
not
only
in
the
Ottawa
homes
but
private
sector
homes
and
other
non
profit
homes.
It's
an
unfortunate
reality
when
people
have
lost
their
mental
capacity
and
diminished
mental
capacity
to
dementia
and
Alzheimer's
in
a
variation
and
I
think
it's
it's
one
of
those
responsibilities
that
our
staff
have
been
taking
that
also.
H
You
know,
communication
issues
happen
along
the
way
in
this,
and
someone
doesn't
follow
a
policy
or
doesn't
think
that
the
situation
applies
absolutely
and
I.
Think
the
author
has
done
a
good
job
in
terms
for
identifying
the
discrepancy
between
our
policies
in
the
ministry
of
long-term
care
policies
which
should
tighten
up
that
process.
So
something
like
this
doesn't
fall
through
in
terms
of
interpretation
of
what
actually
occurred.
So
thank
you
to
the
auditor
and
I
turned
about
to
you.
Mr.
chair.
Thank.
A
C
C
They
were
at
odds
with
the
with
the
legislation,
and
it's
that
type
of
confusion
that
has
to
be
eliminated
to
make
it
very
very
clear
for
the
for
the
frontline
staff
and
the
uncle
manager
when
they're
making
one
met
they're
making
these
these
decisions,
when
an
incident
happens
sometimes
in
the
middle
of
the
night,
sometimes
sometimes
when
they're
on
on-call
they're
in
the
middle
of
other
activities,
and
they
get
called
a
way
to
make
a
decision
and
and
the
policies
and
procedures
should
be
clear.
And
that's
that's
where
we
pointed
out
the
discrepancies,
I.
A
Guess
you
know
not
reporting
the
especially
abuse
to
the
police
and
minister
develop
long
term
care
I.
Guess
it's
a
certain.
What
actions
were
taken
for
a
non-action
of
reporting
is
basically
in
the
report
here.
It
says
that
anytime,
there's
abuse
that
it
should
be
reported
to
police
and
Minister
of
Health
and
long-term
care.
Was
any
employee
reprimanded,
become
someone
action.
C
E
So
the
when
the
event
took
place,
both
families
were
notified.
On
that
very
same
day,
the
information
that
the
on-call
manager
received
was
such
that
the
decision
was
made
that
this
did
not
constitute
sexual
abuse
and
therefore
the
reporting
was
not
required.
The
next
day
they
when
additional
information
was
received,
the
decision
was
made
to
contact
the
ministry
and
the
police
immediately.
The
next
morning
the
ministry
did
complete
their
investigation
and
in
the
end,
there
was
no
findings
of
failure
to
report
or
no
findings
of
failure
to
protect
the
the
resident
I.
A
Mean
I
guess
we're
dealing
with
two
issues,
or
is
that
one
issue
where
the
patient
was
physically
attacked,
which
everybody
was
aware
of
and
then
there's
another
one
witness
sexual
sexual
abuse
were.
Others
was
when
you
did
your
investigation.
I
know
it's
you
who
spoke
to
staff,
then
you
talked
to
residents
at
the
seniors
place.
Also.
C
A
That
maybe
not
be
something
in
the
future
when
there
is
abuse
reports
to
check
what
other
residents
see
if
they're
facing
a
similar
type
of
abuse
or
I've
been
made
aware
of
from
other
residents
about
similar
type
of
abuse.
Many
residents
mystery
seniors
might
be
a
bit
scared
to
come
forward,
but
if
they
are
approached
with
what
has
happened,
you
know
it
might
be
a
good
idea
to
get
their
views
on
it
to
see
if
it's
widespread
or
it
was
if
it
was
interest
one
that's
in
it.
A
In
some
instances
were
seen
that
staff
felt
that
and
the
impression
it
was
not
enough-
follow,
trim
from
management
and
implementing
action
plan
addressing
I
identified
issues
in
the
home
I
know
we
have
the
hotline
when,
in
cases
like
this
Werner,
actually
critical
cases
were
dealing
would
abuse
physical
abuse
and
sexual
abuse.
Is
there
not?
Is
there
a
mechanism
where
staff
could
contact
someone
without
I'm,
in
fear
of
reprisal,
from
from
management
that
they
have
taken
that
action.
C
C
It
has
respectfully
and
handled
the
issues
that
have
been
identified
to
it.
It
has
reported
out.
It
has
protected
the
anonymity
of
the
individuals
who
provide
the
reports,
but,
as
was
identified
in
this
in
this
investigation,
we
have
to
do
a
better
job
of
promoting
it,
and
I
could
say
that
city
manager
and
I,
when
we
met
discussed
at
opportunities
that
we
could
that
we
could
reverse
those
issues,
and
you
will
probably
be
coming
back
to
to
the
committee
with
an
update
on
what
what
our
plans
are
in
that
regard.
Well,.
A
One
thing
that
was
quite
disturbing
is
that
both
incidences
and
they've
identified
that
staff
on
your
frontline
staff,
which
did
a
fantastic
job
me
only
brought
it
up
right
away.
They
brought
up
that
police
should
be
notified
and
it
was.
It
was
decided
by
I,
guess,
senior
management
at
the
time
and
the
resident
that
no
was
not
required.
Wait
until
the
next
day,
then
you
know
they
decided
okay.
Well,
maybe
we
should
report
it
to
two
police.
C
Mr.
chair
I
think
I
think
the
issue
was
the
the
contradictions
that
we
saw.
They
were
identified
in
the
policies
and
we
were
told
that
the
discussion
with
the
on-call
manager
centered
around
whether
or
not
there
was
an
injury
to
the
to
the
other
resident,
and
it
was
the
focus
and,
let's
that's
the
problem
with
that
that
we
identified
in
the
policies
by
focusing
on
the
injury,
the
decision
was
made
and
there
was
no
physical
injury.
No,
there
were
there
were
no
web
wounds,
no,
no
obvious
physical
wounds.
C
A
I
still
go
back
to
you
know
if
there's
if
stuff
as
any
perception
that
they
feel
that
it
shouldn't
be
reporting
to
police
I,
don't
think
we
should
be
questioning
I
think
we
should
be
acting
on
it
immediately
and
that's
a
suggestion
when
we
can
right
now
in
the
city
manager
and
as
we
move
forward.
You
have
to
look
at
that
poor
woman
who
was
in
that
situation
I
mean
to
go
overnight.
A
I
mean
to
deal
with
that
I
think
the
proper
thing
would
have
been
I,
don't
care
what
the
policy
say:
it's
I'm
on
injury
or
whatever.
If
there's
perception
myself
net,
and
then
it's
brought
forward
to
men
instrument
that
would
you
know
you
should
call
the
police
I
think
that
action
should
be
taken
immediately.
The.
H
To
show
we
demand
it
from
if
I
ask
Jonathan
bean
two
questions,
because
I
think
that's
the
counselors
that
you
raise
the
issue.
What
was
actually
what
did
the
staff
actually
tell
the
on-call
manager,
but
calling
the
police
and
I'm
not
sure
that
that
that
was
the
recommendation
of
the
staff?
So
maybe
you
can
just
get
clarification,
but
what
did
the
on-call
manager
I
should
hear
from
the
staff
which
caused
the
confusion?
E
So
from
just
in
terms
of
some
context,
mr.
chair,
the
the
event,
did
occur
one
year
ago
over
one
year
ago,
and
since
that
time,
there's
been
extensive
training
around
failure
to
the
need
to
report
and
abuse
and
neglect,
and
so
one
of
the.
So
there
was
no
discussion
at
that
point
about
calling
the
police,
on
behalf
of
the
original
nurse,
the
information
that
was
provided
in
bold
care,
that's
where
the
documentation
is
and
what
we
have.
E
What
we're
proceeding
with
is
so
that
all
on-call
managers
sees
all
the
reefs,
all
the
information
in
gold
care
to
assist
them
in
making
a
decision
versus
just
what
has
been
communicated
over
the
telephone.
So
that
should
alleviate
that
contradiction
or
that
discrepancy
in
terms
of
the
conversation.
I
can
tell
you
that,
since
this
incident
and
the
the
Auditor
General's
report,
the
policy
has
been
changed
there,
so
that
it
does
absolutely
align
with
the
with
the
ministry
and
that
extensive
face-to-face
training
has
incurred
in
all
of
the
homes.
E
We
will
be
having
awareness
weeks
every
single
weeks
in
the
home,
and
we
have
posters
and
cards
distributed
to
all
staff
to
ensure
that
their
responsibilities
are
clear.
Around
reporting
and
I
just
want
to
turn
it
over
to
Dean
to
talk
about
what
some
of
the
options
that
do
exist
for
staff
who
perhaps
want
to
disclose
their
information.
F
Mr.
chair,
as
indicated
earlier,
there
is
a
toll-free
number
that
any
person
can
call
staff
members,
families,
residents,
visitors,
members
of
the
general
public
if
they
have
any
alleged
or
suspected
abuse
or
neglect
that
they
want
to
report
and
staff
are
encouraged
to
do
that.
Staffer
also
when
they
witnessed
an
incident.
They
are
involved
in
the
reporting.
F
So
the
electronic
submission
of
the
critical
incident
to
the
ministry
is
supported
by
the
individual
that
witnessed
the
event
I
just
going
to
add
a
couple
more
things
in
terms
of
the
training
that
we've
done
in
since
the
event
that
took
place
last
summer,
we've
done
a
100-percent
training
with
over
a
thousand
employees
on
the
prevention
of
abuse.
We
have
a
zero
tolerance
of
abuse
or
neglect
in
our
homes,
and
we
enforce
that
policy.
F
As
Janet
said,
Kenna
said
we
are
putting
an
awareness
week
in
place
in
the
homes
in
June
for
all
four
homes,
and
that
awareness
is
not
just
for
our
staff,
but
is
for
our
families,
our
residents
and
our
volunteers.
The
abuse
policy
is
reviewed
annually
or
as
needed,
and
in
some
cases,
if
a
ministry
comes
in
and
identifies
an
area
in
our
policy
where
there
may
be
a
knock
came
to
improve
those
improvements
are
put
in
place
right
away
and,
as
Janice
said,
we've
posters
in
the
homes.
F
A
Mr.
charity,
sir,
yes,
sir
one
follow-up
and
I
think
thank
you
for
the
proactive
approach.
I
think
it's
something!
That's
it
I
guess
in
closing,
if
an
employer
infinite,
if
an
employee
does
see
a
scenario
where
he
feels
or
she
feels
that
police
should
be
notified,
is
that
the
policy
that
they
will
notify
the
police
immediately?
A
F
A
Will
not
be
questioned.
Take
no
much
mistake.
Your
counsel
know
that
cuts
our
interior
well.
I
think
that
was
going
to
be
my
question
about
the
police
and
I
think
councilman
that
they're
a
good
job
asking
those
questions
so
I'll
stand
down.
Sir
chairs,
that's
really
good!
Thank
you.
It
council
welcome
to
thank.
G
G
G
People
work
there
too,
that
the
staff
themselves
are
often
abused
by
the
patients
and
often
even
hit
and
do
and
I
just
wondering
what
is
our
policy
for
dealing
with
situations
when
a
staff
is
actually
becoming
physically
abused
by
a
patient,
because
these
patients
with
dementia
and
things
often
don't
know
what
they're
doing
and
and
it
can
be
quite
severe,
I
just
and
I
haven't
heard
it
talked
about.
We
talked
about
the
patient,
but
it
goes
the
other
way
as
well.
F
Mr.
chair
I,
just
like
to
highlight,
be
the
demographics
of
the
clients
that
we're
serving
40%
of
our
residents
exhibit
moderate
to
severe
aggression
that
can
be
yelling
swearing
punching
hitting
spitting.
These
are
the
types
of
things
that
our
staff
are
subjected
to.
We
have
supports
for
our
staff.
We
work
very
closely
with
the
Royal
Ottawa
outreach
team
around
de-escalation
of
behaviors
and
working
with
them,
and
also
providing
the
training
to
our
staff
in
order
to
be
able
to
do
so
in
a
safe
manner
as
a
last
resort.
F
If
we
have
a
resident
who
we
are
not
able
to
manage
in
the
home,
we
would
send
them
out
the
hospital
until
their
care
plan
was
stabilized
and
we
can
bring
them
back
into
the
home.
In
addition
to
that,
in
each
one
of
our
homes,
we
have
PSW
behavioral
support
champions
that
are
available
as
well
to
support
staff
in
developing
the
appropriate
care
plan
to
provide
care
in
a
safe
manner.
F
G
And
I
think
this
also
outlines
the
issue
about
how
we're
staffing
our
facilities.
Now
they
they
have
of
you,
mentioned
change
drastically
in
the
last
25
years.
They
used
to
be
acting
more
like
a
retirement
homes.
That's
now
they're,
no
longer
that
way.
They're
now
have
the
average
ages,
usually
over
90
and
the
level
of
dementia
has
increased
significantly,
and
it
is
sad
to
see
but
I
think
it
does
require
us
as
a
community
that
we
actually
put
the
resources
in
place
and
I.
G
G
And
I
should
buy
the
auditor-general,
that's
right
on
this
particular
case.
They
moved
him
some
time
later
to
in
all
the
mail
section
of
the
building
as
a
way
friend
where
a
lot
of
women
were
around
I,
just
wondering
why
a
that
was
not
done
even
earlier,
he'd
been
exhibiting
features,
but
even
if
I,
why
isn't
done
generally?
In
any
case,
because
these
kind
of
things
can
happen
when
you
have
them
close
together?
We
all
know
that,
yes,
mr.
F
Chair
we
do
move
residents
around
when
they're
not
appropriate,
for
a
specific
area
in
one
of
our
homes,
we
do
have
a
designate
designated
male
unit,
where
residents
of
the
nature
that
was
described
in
this
incident
would
be
placed
for
everyone's
safety.
However,
the
homes
are
full
and
in
order
to
move
somebody,
we
need
to
make
sure
that
we
have
an
empty
bed
to
be
able
to
move
them
to
another
room.
G
B
C
B
We're
okay
I
want
to
focus
on
page
22
of
the
report
and
a
comment
by
Ms
Brennan
with
respect
to
the
the
person
had
exhibited
behavior
earlier
in
the
day
that
caused
concern
to
staff
I
guess
my
question
is:
what
are
the
procedures
that
are
in
place
with
respect
to
the
person
who
exhibits
that
short
of
moving
them
to
another
unit,
and
and
were
those
procedures
followed
and
missing?
Perhaps.
F
Mr.
chair,
as
I,
said
earlier,
we
work
very
closely
with
the
Royal
Ottawa.
When
we
have
a
residence
with
aggressive
behaviors.
We
would
often
have
what's
referred
to
as
a
PRN
which
is
per
resident
needs,
and
that
would
be
an
intervention
we
would
use
if
we
were
dealing
with
an
aggressive
resident
and
we
were
trying
to
control
them
for
their
safety
and
the
safety
of
other
residents.
We
would
look
to
give
them
a
medication.
F
F
B
The
incident
so
he
exhibited
aggressive,
behavior
or
inappropriate
behavior
I,
believe
the
report
says
earlier.
In
the
day
medication
was
administered.
There
was
no
one-on-one
at
at
time.
What's
there
mr.
chair,
that's
correct
and
the
incident
did
occur.
Yes,
our
policies
being
reviewed
with
respect
to
how
effective
they
were
in
this
instance.
Mr.
F
Chair
staff
are
being
educated
that
if
they
witnesses
an
incident
of
aggression
with
the
resident
it
be
reported
immediately,
and
if
there
is
a
an
immediate
danger,
we
can
apply
for
one-on-one
staffing
and
that's
covered
through
the
ministry's,
high-intensity
needs.
So
that's
the
direction
we're
applied
to
stop
if
they
had
an
individual
who
we
were
not
able
to
keep
safe
and
then
we
would
look
at
potentially
moving
them
to
the
hospital
if
the
behavior
continued
and
we
were
not
able
to
control
it.
Okay,
you.
B
F
B
Reporting
nurse
says
she
said
to
the
on-call
manager
and
and
that
person's
interpretation
of
the
fact
and
from
a
control
point
of
view.
Is
there
any
way
that
we
can
improve
the
reconciling
of
of
those
two
differing
accounts,
because
it
appears
that
only
after
the
fact,
the
next
day,
the
second
RN
on
the
second
RN
escalated.
The
situation.
F
Mr.
chair,
we
are
curling
the
process
of
developing
a
reference
document
with
standardized
intake
questions
so
that
we're
asking
the
right
questions
when
an
incident
or
'td.
In
addition
to
that
today,
our
managers
have
access
to
the
healthcare
records
of
the
residents.
The
reside
in
that
specific
home,
we're
now
working
with
our
software
to
enable
our
managers
to
have
access
to
all
Resident
charts
across
the
four
homes.
So
they
can
go
in
and
read
progress
notes
relating
to
any
incident
that
may
have
occurred.
Are
you
referring.
F
That's
correct,
Dee,
and
now
they
do
they're
going
to
be
given
that
access
we're
in
the
process
of
putting
that
in
place.
As
I
said,
they
have
access
to
their
own
residents
within
the
specific
home
they
work
in
and
we're
going
to
open
it.
So
they
have
access
to
all
over
700
healthcare
records
and
in
this.
B
C
Cherrick,
the
recollection
of
the
of
the
nurse
was
the
same
as
what
was
as
the
was
the
same
as
the
incident
was
reported
by
the
other
observers.
It
was
the
same
as
the
information
in
gold
care.
The
only
thing
that
differed
was
the
recollection
of
the
on-call
manager
and
the
notes
that
that
on-call
manager
made
in
in
the
on-call
report
and
the.
B
C
A
You
coochie,
no
other
questions.
I'll
just
ask
a
couple
of
my
own
here.
I
think
this
report
goes
to
why
many
of
us
get
involved
in
public
service
and
employees
as
well,
because
we
want
to
be
there
to
help
people
when
they
need
our
help,
and
what
this
report
highlights
is
where
the
system
I
don't
know.
If
we
want
to
call
it
broke
down,
but
it
certainly
let
down
the
resident
involved
in
the
so
my
question
to
mr.
A
Ellis,
if
you're
telling
them
to
call
this
provincial
toll-free
number
and
my
mind,
that
would
not
have
helped
in
this
case,
because
the
provincial
policy
says
there
has
to
be
an
injury
yet
in
our
workplace.
You
know
there
doesn't
have
to
be
an
injury
if,
if
you're,
if
someone's
harassing
you
were
especially
in
this
scenario
here,
if
they'd
taken
you
in
a
room
and
gave
every
indication
they're
preparing
to
have
sex
with
you,
I
think
we
would
react
a
whole
lot
different.
A
E
So
mr.
chair,
the
the
I
think
you
may
be
confusing
the
two,
so
the
requirement
that
they
contact
the
Ministry
is
in
the
case
of
abuse,
alleged
or
actual
abuse.
That's
that's
witnessed
so,
and
that
includes
contacting
the
police
as
well.
So
that's
one,
that's
the
one
option
and
that's
where
the
auditor
had.
E
We
pointed
out
that
there
was
a
discrepancy
between
the
policy
and
the
practice
of
the
of
the
city,
so
that,
since
been
resolved,
the
other
hot
line
is
an
opportunity
for
any
staff
that
has
issues
or
concerns
whether
and
that
includes
families
and
volunteers
as
well.
That
may
want
to
call
and
report
something
other
than
that
duty
to
report
to
the
Ministry
on
instances
of
abuse
or
neglect.
So
those
are
two
different.
We.
B
F
Mr.
charity,
the
incidence
of
injury
are
related
to
physical
assault
between
two
residents
and
the
definition
within
the
ministry
states
that,
if
there's
no
injury
you're
to
continue
in
put
in
place
the
appropriate
actions
to
protect
those
residents.
But
if
there's
no
injury
documented,
the
legislation
today
reads
that
it
does
not
need
to
be
reported
to
the
ministry.
Okay,.
A
F
A
Let's
go
back
to
how
he
got
in
there
in
the
first
place,
I
thought
I
thought
you
were
suggesting
that
it
was
because
there
was
in
a
room
for
him
if,
if
we
already
knew
this
gentleman
had
these
issues
and
needed
help
with
dealing
with
that,
how
did
he
end
up
in
a
women's
ward
like
there
to
me?
That
would
have
been
the
last
case
scenario
where
you
would
want
to
put
somebody
that's
showing
these
symptoms
so.
F
A
All
the
other
words
would
be
the
same
as
this
with
the
exception
of
the
all-male
one,
that's
correct,
so
the
other
ones
wouldn't
have
been
any
safer
for
the
residents
if
he
had
been
put
in
there.
That's
correct,
okay!
Thank
you.
Okay,
thank
you,
mr.
Aldo
general
them
for
your
report.
Going
back
to
the
agenda
here.
So
I'll
read
this
out
that
the
audit
committee
received
the
reports
on
investigations
into
the
long-term
care
homes
and
recommend
that
council
consider
and
approve
the
report
recommendations.
Is
that
received
and
carried
this?
Thank
you.
A
Right
here,
yeah
sorry,
so
item
number
two,
which
is
the
status
update,
that
the
Audit
Committee
inquiries,
emotions
for
the
period
ending
13th
April
2018.
This
item
received
okay
now
I
also
need
to
ask
that
we
confirm
the
minutes
for
member
14,
which
were
the
30th
of
November
2017
in
the
committee
confirm
those
minutes.
Thank
you.
Any
notices
of
motion
any
inquiries.