Report shows need for more training, monitoring, planning

Interior Health’s internal investigation into a case of patient-on-patient violence that ended in the eventual death of Overlander Extended Care resident Jack Shippobotham points to several areas where improvements are needed.

The report, titled Addressing Complex Behaviors in IH Residential Facilities, says all of the actions listed in the document are at some stage of planning or implementation.

Here’s a summary of recommendations in the report.

• In specialized, chronic-behavior disorder units (such as for dementia patients), improved communication processes will be created to reach outside support in emergencies.

• More orientation will be done for staff regarding the patient safety learning system.

• Creation of a working group involving all sectors of people caring for those with complex behaviours and needs, with a focus on seniors’ mental health. The group will review the admissions process and implement the B.C. Seniors’ Plan and Ombudsperson’s report on Best of Care for seniors.

• Two educational/training initiatives are being put into place throughout the health authority involving dementia and senior patients.

• Where possible, the creation of one-resident rooms in care facilities.

• Developing a process for reaching out to families and staff involved in significant harm or death situations.

• Ensuring a standardized approach to care planning and care conferencing.

• Regular meetings to discuss safety of residents and staff as well as any challenges and concerns.

• Where needed, making modifications to support staff monitoring of clients and enhance client safety. This can include improving visibility of some areas using mirrors, better night lighting, and keeping charts in central locations.

• Exploring the role of nurse practitioner positions to deal with behavioural management and enhance support at care facilities.

• Developing “an implementation plan for action items identified through the review that is realistic, measurable and supported with required resources.”