‘I trusted this facility… biggest mistake of my life’

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This article was published 27/02/2025 (192 days ago), so information in it may no longer be current.

The daughter of a Winnipeg senior claims negligence by two personal-care home employees led to a fall that left the great-grandmother with broken legs.

Dawn, who requested her last name be withheld, said the agony her mother Edna, 87, suffered at Extendicare Tuxedo Villa in June 2024 could have been avoided.

“I trusted these people. They failed my mother,” Dawn told the Free Press. “They took her dignity, they took her freedom. There’s no accountability here. It’s like nothing ever happened.”

“They took her dignity, they took her freedom. There’s no accountability here. It’s like nothing ever happened.”–Dawn

Edna, who had dementia, used a wheelchair because she was unable to stand on her own. Dawn believes the fall contributed to her mother’s death in January.

“She was in a building she loved. She would scoot around and visit her friends,” Dawn said. “After this happened, she went downhill. She couldn’t do anything anymore. I think she just gave up.”

The Winnipeg Regional Health Authority conducted a critical incident review, which led to an apology, she said. Tuxedo Villa is one of 14 Manitoba care facilities owned or managed by Ontario-based Extendicare.

Dawn said an Extendicare official told her two aides were moving her mother in a sit-to-stand lift when the senior “fidgeted,” slipped down and was gently lowered to the floor.

She claims an employee, who was not involved, told her that her mother was not properly restrained on the lift.

Dawn alleges the lift was not inspected regularly. She said a different type of lift with a hammock should have been used.

She claims the aides returned her mother to her bed and did not report the fall. She said a nurse phoned her when staff on the next shift suspected her mother’s right leg was broken.

“I was taken aback. How is that possible for someone who didn’t walk?” Dawn said. “It was absolutely horrific. She was crying so much from the pain.”

At a hospital, Edna had a cast put on her right leg, which was broken in two places. When she returned to Tuxedo Villa late at night, Dawn said she helped her mother into bed because the care home lacked staff.

Fractures to Edna’s left leg were not discovered until two days after the fall, when the leg became swollen, her daughter said. Edna returned to hospital, where her left leg was put in a fracture boot.

Dawn later asked her mother if she understood what happened.

“She just said, ‘They took my legs,’” Dawn said.

She said her mother was confined to her bed for four months, requiring employees to turn her every two hours.

Dawn said she was told the two aides returned to work after being placed on leave. She told management she did not want them involved in her mom’s care.

The WRHA later shared the critical incident review’s findings at a meeting.

Dawn provided a copy of the WRHA’s summary, which indicated staff did not recognize that the incident required fall protocol to be implemented, and assessments were not completed accordingly.

Staff could have switched to a different lift and transfer method, but they didn’t know they were able to change processes based on a resident’s condition at the time and without “expert consultation.”

The letter said an inspection determined the lift’s knee pads needed to be replaced. It also cited gaps in communication between workers’ shifts.

“We apologize for the harm that your mother experienced and for the gaps that contributed to a delay in assessment and intervention,” the letter said.

The review produced two recommendations: retraining and a checklist for lifts and transfers, and education around fall protocol and assessments of residents who are being transferred.

“If you see something wrong, get involved. Never be scared to ask questions. I trusted this facility 100 per cent, and it was the biggest mistake of my life.”

An Extendicare spokesperson said staff were re-educated on best practices for patient transfers using mechanical lifts, and policies and procedures about the use of the equipment were reviewed.

The spokesperson said Extendicare worked with “union partners” to ensure there was “appropriate” discipline to the staff in question. The company did not reveal how the employees were disciplined.

“The care, comfort, and safety of our residents is our most important responsibility. We maintain a safe and secure environment through continuous learning and a comprehensive suite of care protocols and reporting procedures,” the spokesperson wrote in an email.

The spokesperson said Extendicare ensures there is adequate staffing at all times, and third-party assessments of equipment are routinely conducted.

A WRHA spokesperson said critical incident reviews and recommendations focus on “system level opportunities” to improve safety, and do not investigate the practices of individual employees.

The Protection for Persons in Care Office, which looks into reports of alleged abuse or neglect, opened an investigation.

“As per our usual practice, our long-term care team will continue to visit and support the site and work with Extendicare to ensure they meet our expectations of providing safe, high-quality, compassionate care to residents in their care homes,” the WRHA spokesperson said.

Dawn emailed the offices of multiple politicians, including Health, Seniors and Long-Term Care Minister Uzoma Asagwara, in July to raise concerns. Most did not reply, she said.

Asagwara said their office forwarded the concerns to the WRHA’s patient relations office.

“We take concerns like this seriously,” Asagwara said. “A situation like this is not something we want to see, and certainly we want to ensure there are lessons learned from this to ensure that residents like this person can trust and feel confident they’re going to receive the right care and be safe in their home.”

After the fall, Dawn met regularly with Tuxedo Villa management to discuss her mother’s care plan. She obtained copies of nurses’ and aides’ notes.

In her final months, Edna was able to sit in a wheelchair that changed position, allowing her to spend time outside her room. Her dementia got worse before she died Jan. 17, Dawn said.

Dawn said she decided to speak out about her mom’s experience to make people aware of issues within the system and their rights.

“You have the right to see the notes, the comments and things on file,” Dawn said. “If you see something wrong, get involved. Never be scared to ask questions. I trusted this facility 100 per cent, and it was the biggest mistake of my life.”

Dawn said she considered a lawsuit, but was deterred by the potential for high legal fees.

chris.kitching@freepress.mb.ca