Pauline Lahache has been visiting her husband Billy Two Rivers in the hospital for many years, but it was only fairly recently her intuition told her something was seriously off.
Billy, 87, was groggier than usual and sleeping a lot more.
Around April of this year, his wife said he was “constantly out like a light, sometimes three or four days.”
Nurses used possible dementia as an excuse, she said, to try and explain Billy’s state of mind, but Pauline wasn’t buying it. She pressed a new nurse who was at the Kateri Memorial Hospital Centre (KMHC) from another hospital, and she came back with news that Billy was on quetiapine – a potentially dangerous drug.
“Quetiapine is used alone or together with other medicines to treat bipolar disorder (depressive and manic episodes) and schizophrenia,” according to the Mayo Clinic. “This medicine should not be used to treat behavioural problems in older adult patients who have dementia or Alzheimer disease. Quetiapine is an antipsychotic medicine that works in the brain,” it concluded.
Pauline demanded the hospital stop using quetiapine because the side effects in elderly patients could lead to death.
“I said, ‘It’s discouraging and disgusting what you’re doing in here. That pill is never to be given to my husband again.’ I told them I will know if they’re still giving it to him and they have to stop, now,” she said. “It’s killing him, it’s killing me, and it’s killing my family.
“Billy was sent to the neurologist twice and there was nothing wrong with his brain,” said Pauline, who felt her husband was being silenced secretly because he is unafraid to speak up when something is wrong.
“I was hallucinating and in my hallucinations I must have been wrestling or fighting with somebody,” said Billy. “I was in that motion, of punching around. So their conclusion was they were going to give me that pill. It was supposed to be a calming pill, but it almost killed me.
“I took the whole thing and I collapsed. They couldn’t revive me. That’s what I was told. So they sent me to Anna Laberge on a Friday and I woke up Sunday evening,” he said.
Billy expressed worry about others at the hospital in the long-term inpatient unit and how they’re being treated, especially the ones who have no family or are non-verbal.
“A lot of those workers are worn out, tired out, but they’re too cheap to hire more,” Pauline said.
Part of the problem, she feels, is the lack of training for new staff.
“They hire people that don’t know. They don’t know the people and they don’t know what to do sometimes. They’re not teaching them. They’re just putting anybody in there and there’s a big lack of communication,” she said.
“I feel bad because some of the nurses are working hard. A lot of them are really good and dedicated to their jobs, but not all of them,” she continued. “Some of them see things but won’t say anything because they are afraid to lose their jobs.”
On top of the many issues expressed, Pauline also had to fight to be listed as her husband’s caregiver. This meant that at times like Christmas during the pandemic, she could not see him or bring him gifts, she said, which left her in tears.
His wife also said merely getting someone to answer the phone is a huge, ongoing issue.
“You know how many times I had to jump in my car, even if I don’t feel good, because they’re not answering their phone? I don’t like to drive in winter, but I had to many times,” she said.
At times her husband’s phone had been moved away from him, so the communication between the couple of 55 years was completely cut off.
“I said, ‘What is wrong with you? You know he can’t get out of bed to grab the phone. Put the phone back in his reach,’” she recalled telling the nurses.
To make matters worse, when Pauline requested Billy’s medical file, she was told she didn’t have power of attorney, and he would have to sign the papers to gain access to them. But he hasn’t been in the best of health lately to do so.
“I’m fed up with this,” she said. “This has to get out there and people have to know what’s going on at our hospital.
“A lot of those elders there, their loved ones don’t know them anymore,” said Pauline. “You still need to check on them. Who knows what these pills have done to them?”
The family has consulted a lawyer, who visited Billy this week – a period of time that Pauline said was especially hard on him, as he struggled to stay awake.
Concerned for her mother
“The care that she is receiving right now, recently, has been really good since her fall in April,” said Tracey Snow, after her mother Ruth broke her hip a couple of months ago. “As difficult as it is to point out the shortfalls of Kateri Memorial Hospital, I feel like it has to be addressed. And the only reason why we’re doing this is because we want to see an improvement, and changes are needed.
“I don’t know where or how that improvement has to happen, but something has to happen,” she said.
Tracey and her family have grave concerns with the long-term care at KMHC.
“I don’t want to put the blame on any one person,” she said. “I think that most of the staff there are trying their best to do their job.
“But mistakes are happening that shouldn’t.”
Staffing issues are a known problem across the province and have contributed to the current situation. Incoming nurses or PABs (attendants) don’t know the community, or, more importantly, don’t get to know the individual patients and their charts adequately enough, which leads to errors in proper delivery of medication, and misunderstanding; or at times not attending to obvious needs, she alleged.
“I felt like, well, if you’re understaffed, why do you have this many patients? If you can’t offer the quality and important job that you have to do here,” she said.
“Especially in Kahnawake, I think we should be doing so much better. We put our elders at such a high respect level, and we’re allowing this to happen in our community. And this isn’t a new issue,” she added.
“A week before she fell and broke her hip, she fell and sustained a lesion on her leg,” said Ruth’s daughter Penny, who is a licensed practical nurse. “Her room wasn’t walker or wheelchair accessible to get around.
“So after waiting a week for the occupational therapist to assess the room, I got one nurse to check the books and she came back to tell me that OT (occupational therapy) was not consulted. I called OT to let them know that Tracey and I went into the room and rearranged it so that everything was open and she can move around with her walker with assistance,” said Penny.
Ruth was in extreme pain transferring from bed to chair, chair to bed, bed to commode, something her daughter Penny put in to help her go to the bathroom, so it could be close to her bed.
Tracey’s mother Ruth was admitted to KMHC in 2018, close to Christmas. She was diagnosed with dementia. The family tried to keep her home, but the 24-hour care was too much to handle, on top of day-to-day issues and Tracey’s job at the Public Safety Unit at the time.
Originally, it was for a weekend to give the family a break, but it eventually turned into a long-term stay.
Trying to admit her mother to a hospital without her knowledge and understanding was heartbreaking for the family.
“That’s the first thing I suggested with them was they should have support for families that are putting their loved ones in their care, because it’s quite an ordeal,” said Tracey.
Ruth was admitted into short-term at first, and was given antidepressants without her knowledge, said her daughter.
Two weeks after being admitted, Ruth needed to be rushed to Anna Laberge Hospital.
“What happened was her sodium levels dropped due to medication given – anti-depressants – and she ended up going into full blown seizures and could have died. She had to be admitted to Anna Laberge for a week to get her sodium levels to a normal level,” said Tracey.
Tracey and her family put rules into place that before the KMHC nurses or doctors administer any type of medications, they notify the family or herself. Tracey had the sole power of attorney at the time, a task that has now been spread out to her sisters as well.
“That never happened,” Tracey said. “They would either decrease or increase medications. And maybe that’s a normal practice within these institutions, I don’t know, but they would never let me know when they were doing something like that.”
When the pandemic hit, the family faced a new set of challenges. Tracey alleges that the hospital was not regularly changing her mother’s bedding or bathing her.
“I know this because I started looking at her bed sheets. Her pillows were filthy, her bed sheets were filthy, they’re full of crumbs, stuff that she spilled,” said Tracey.
To confirm her suspicions, Tracey took a black marker and marked the sheets.
“And that occurred throughout that whole year. I have to keep getting after them to change her bed sheets and I wrote letters of complaint saying, ‘Listen, you guys are not changing her bed sheets, it’s been three weeks and I know this because I put a marker on one and I started keeping a diary, writing all these things down,’” she said.
Hospital administrators told her that things would change, but little has.
“It would get fixed for maybe two weeks and then it would slowly go back to being the same way,” she said.
Ruth developed osteoporosis fractures and was in a lot of pain in her lower back for weeks. The family alerted hospital staff until finally they had to demand an x-ray.
“They didn’t want to take her for an x-ray,” said Tracey. “Turns out, she had osteoporosis fractures in her back. So that would have meant a whole new pain management plan because they all have an individual care plan that they’re on for their medications.”
Tracey also alleges that pain management was not keeping up with the actual pain her mother was suffering.
“She was in pain, she was shaking, she was crying. My sister (Penny) walked in and said, ‘What the hell is going on? Where’s her medication? Can I see her chart?’”
They were reluctant at first.
“Finally, my sister got a hold of it, only to see that they hadn’t even given my mother her required pain and panic medication for that day,” said Tracey. “She could have had a heart attack.
“It’s been exhausting to say the least to deal with them and making sure that my mom was taken care of, that she’s receiving her medications on time,” she said.
In the most recent incident, Tracey said, Ruth broke her hip because she developed osteoporosis fractures in her back for the second time.
“In between the first and second osteoporosis fractures, they started to give her some injections that were supposed to prevent future fractures,” she said.
With Ruth’s second diagnosis of osteoporosis fractures, “they gave her a walker to use and a cane, but she’s got dementia,” said Tracey. “So she’s going to just try to walk. And I think that’s what happened and they found her on the floor. She broke her hip. So we had to rush her to Anna Laberge.”
Ruth had to have an operation and a rod was put in her leg and pins in her hips, “at 85 years old, because of something that was preventable,” said Tracey.
“And the fact that we just finished addressing it with the director and saying, ‘Listen, something has to happen here.’ These are too many shortfalls, and I don’t want to hear that you’re understaffed. We need somebody to come in and watch her to make sure that she doesn’t fall,” she said.
The family wrote five letters of complaint to address the situation, but were unhappy with the responses.
“One time we took her out to get her hearing aids fixed, she looked like a homeless person. Her hair was so greasy, it was stuck to her head,” said Tracey. “It was so bad, when I picked her up, I was just appalled. I was like, Jesus Christ.”
A voice for her brother
Carla Skye feels fortunate to have family working at the hospital, but her brother Carl is non-verbal and has Down Syndrome. Keeping an eye out for warning signs became an especially high point of stress recently, when a couple of harrowing incidents left her and her family fearful.
“Three months ago, he strangled himself with his blanket. They don’t know the details because he has a lot of seizures, especially in the last two years. They don’t know if the seizure caused the strangulation or if the strangulation caused the seizure,” she said.
“I personally brought in my baby monitor so they watch him at night from the nurse’s station and a PAB noticed something didn’t look right so she went to check on him and found him choking with the blanket around his neck. We are grateful for her quick response.”
Weeks later, Carl had another seizure. This time, Carla said, the nurse in charge did not follow protocol and too much time had elapsed before Carl was tended to.
“He had his seizure at approximately 5 p.m. The family was called at 5:25, to notify us that he had a seizure, when we arrived at 5:45 we walked in his room to find him lying on his back with very shallow breaths, his oxygen was not administered and his anti-seizure medication was given after the fact,” said Carla.
“The number one rule after he has a seizure is to put him on his side and give him oxygen. The number two rule is to give him the medication if he is still seizing after five minutes. In this case he was not seizing after five minutes and the medication was administered. This episode knocked Carl out until morning the following day and he has never been the same,” she said.
Carla said, “in this particular circumstance staff had no idea what to do.” There is a doctor’s protocol in place, but it went unread. The problem here was “lack of staff” and “lack of communication,” according to the family.
A couple of weeks ago he had another seizure that went unnoticed. The family identified it themselves. At 7 a.m. Carl was extremely lethargic, he had little to no motor skills the entire day and he slept most of it. It took him until early afternoon before he could gain 100 percent consciousness.
“He ate breakfast and lunch with his eyes closed and couldn’t walk until early afternoon,” said Carla. “Because it went unnoticed, he didn’t get the oxygen he needed and we found out that the seizure was caused because his medication was not given before he went to bed. Again, this is because of lack of staff and lack of communication,” she said.
Those incidents scared Carla and her family. Because Carl is non-verbal and cannot express his needs to staff, the hospital management is now trying their best to accommodate and make positive changes with the Skye family by implementing procedures, such as a collage of Carl’s needs placed in the nurse’s station and in Carl’s room, Carla said.
They are also currently working on a five to 10-minute video of Carl’s everyday needs from morning to night as well as his seizure protocol, and have recently installed a camera so they can watch him from home.
“In the past few months, we the family have met quite a few times with hospital personnel and we know they are doing their best in trying to make positive changes for Carl,” she said. “We also understand that the current employees are doing their utmost best to provide quality care. However, there is only so much quality care they can do if they are short-staffed.”
The family’s greatest fear as Carl’s caretakers is that the lack of nursing and PAB staff may lead to more serious situations for all residents.
“This issue needs to be rectified immediately as we have our most vulnerable community members and elders in the care of KMHC,” she said.
“A suggestion would be to have more families and volunteers involved until more staff can be hired. We are confident that Kateri Memorial Hospital will find a solution to address Carl’s needs and the needs of all patients,” said Carla.
Former staff speak out
Cher Nolan was hired as a PAB in December, 2021 and was terminated a few months later on April 5, in part, she said, because she spoke up about what she saw.
“I had a full-time job in Cornwall that I left to come here,” she said, “to be on a contract for a year, thinking that I would get a job after.”
In her short experience at KMHC, she was upset by the things she observed.
“The residents don’t get changed. They don’t force them to get changed either. They say ‘Oh, we’re gonna change it.’ And if the elder says ‘Nope’ the PAB will say ‘Okay, never mind.’” said Nolan. “They just walk away. They don’t really take care of them as they should. But some people are not getting changed at all.”
In one instance she said a man was left in his urine for a long period of time.
“I said, ‘Oh, look, his bed is all wet.’ and she (PAB) says, ‘Yeah, I know, It’s okay.’ And I’m just standing there and he says, ‘I’m freezing, I’m freezing’ and I went behind him and I’m like, ‘Well, he’s soaking wet. So that’s why he’s freezing.’”
When nothing was being done, Nolan said she took it upon herself to try to change him, but the PAB came back.
“She caught me and she’s like, ‘Oh, you can’t be doing this by yourself, you can’t do nothing.’ And I’m like, ‘Okay, well, I’ll help you change him,’ and she responded ‘No, no, we’re going to tend to him later. We’ve got to hand out dinners, we’ll get back to him.’
“So it’s just feeding him in his piss. I was so disgusted. I was standing there like, I didn’t know what the f*ck to do. I felt like a piece of shit,” she said.
To make matters worse, her then-colleague told her they had to go on break before he would be changed, she said. He was only changed later on, said Nolan.
The man’s daughter chewed into hospital staff for leaving her father in that state.
It wasn’t the only incident she witnessed of elders who were allegedly being neglected, she said. In another, a Kahnawa’kehró:non in his 90s waited too long for the PAB to bring him to the bathroom so he peed his pants. He couldn’t open the bathroom door and, according to Nolan, was soaked down to his knees.
The hospital worker in question, Nolan alleges, was smoking a cigarette when this occurred. Nolan also alleges some of the PABs handle the elders too roughly when changing them.
“They could break their brittle bones,” she said. “But they just don’t care.”
Since being fired, she has moved on to the Riverside Elder’s Home in Kanesatake.
Family takes action
One Kahnawake family saw too many issues with KMHC’s staff and decided enough was enough, as they pulled their mother, who we will call Roslyn, out of long-term care.
“Beyond disappointed” was their response when asked about their mother’s stay. “We trusted them to care for our queen and they failed her. My sister went in on Saturdays and me on Sundays,” said the anonymous source, who we will refer to as Lee.
After a couple of Saturdays Lee noticed her mother’s sheets, were dirty and started changing them herself. After she did, she put a pen mark in the corner, and the next Saturday the same pen mark was still on the sheet.
The COVID-19 pandemic made it more difficult for Lee and her sister, whom we will call Rose, to see their mother, but the biggest issue was how short-staffed KMHC was. Some orderlies and nurses were unprepared, not properly trained or just didn’t care, they said. Lee and Rose, along with their family, were left with a lot of anxiety about having their mother at KMHC.
“They blamed it all on COVID and lack of staff, but these things have been going on before COVID,” said Lee. “The problem is they are not supervising their staff properly, there’s a lack of communication between them, and some just not giving a crap about their patients. They say there is always someone at the nurse’s station to take phone calls, but that’s BS! They may be there, but no one answers the phone or returns calls.”
In another instance, Roslyn needed to go to the bathroom, but was told to wait numerous times. She ended up soiling herself due to the long wait and was scolded by the PAB because she had to change all her clothing, according to the sisters.
It wasn’t an easy decision to put Roslyn in the long-term care unit in the first place, said Lee.
“I could no longer take care of her myself; it was just too much. I had been taking care of her myself since she started her illness, and I was beyond drained.”
Roslyn started out in the short-term unit but when it came time for her release after three months, the family asked if she could stay. She was treated warmly in short-term, according to the family.
Their mother “was a very caring and compassionate person who always helped anyone,” said Lee. “She raised seven children and worked hard her whole life, making it detrimental to her independence when this awful disease (PSP, progressive super neurological palsy) took over her life, preventing her from doing things for herself.”
The family didn’t see the issues right away, but eventually noticed her care was dwindling.
“My sister and I were the only ones allowed in to see her because of COVID once a week each, which was the hardest thing I’ve ever done,” said Lee. “I lived with my mother forever but we put her in there to keep her safe, so I had to live with the restrictions.”
Sadly the lack of attention to their mother wasn’t the only thing that irked the family. She enjoyed her ginger ale and one day her family sent some in for her during Sunday drop off.
“When I went in that afternoon she didn’t have her ginger ale,” said Lee. “I asked for it and they told me she was on fluid restriction, which I knew she wasn’t. They went to double check and had her mixed up with the woman two doors down with the same first name.”
When Rose went in to see her that Saturday, Roslyn was weak, pale, dehydrated, feverish, and could not get out of bed, her daughter said.
“Her cup of water, which needed to be thickened now due to her condition, was just out of arm’s reach,” said Rose.
“We had enough and I called a family meeting the next day. I was taking her out of there before she died. I went in to see her that Sunday, talked to her social worker, and told her ‘That’s it, she’s coming home, she’s not being taken care of in here and we want her home,’” she said.
Once home, it took a few days, but Roslyn was almost back to normal. She was even able to swim in her pool last summer. Sadly, she passed away at the age of 80 after being home for seven months.
“Without a doubt in my mind, if we hadn’t taken her out when we did she would’ve died that week,” said Lee.
For their part, KMHC acknowledged that many things have to be fixed, but also cautioned that unfortunately, with so many moving parts, new employees, a shortage of workers across the province, and other issues, mistakes are part of the process.
When asked for comment to help alleviate fears in the community, Lisa Westaway responded to THE EASTERN DOOR in a video conference call with two other staff members: Valerie Diabo, director of nursing, and Mendy Sananikone, manager of Quality, Risk Management and Innovation.
“If it was my family, I would fight tooth and nail to make sure that it doesn’t happen again or to reduce the occurrence, because I know that reducing the risk to zero is absolutely impossible,” said Sananikone.
“We want to increase the partnership with the families. And this is where I think it’s the key element to actually moving forward. We want to see from the family perspective, what do they think can be done together?”
A big part of that transparency and mutual cooperation is sharing information openly.
“We have to give them the information of what happened during these accident events,” Sananikone continued. “So we want to work with the families and learn and get to know what their perspective on the situation could be, and can they maybe find an innovative situation where we can all work together in helping one another?
“So in that sense, it’s not only just about education, but putting safety nets. We call them family partners and it’s how we believe we’re going to be able to get a greater view of all this, the problem and the solution that we can put in place,” she said.
Sananikone was hired to ensure better accountability and has been assessing what needs to be changed at Kateri Hospital.
“An event can be considered an incident or an accident, depending on the seriousness – how it impacts the patient themselves,” said Westaway. “We have legal responsibility and the reporting in the analysis of these events, and in the action plans that are implemented, so you have action plans for each individual event.”
But, she added, the hospital also looks at a summary of what the events are. Patterns are analyzed quarterly, or sometimes more often.
Part of the action plan means those events – incidents or accidents – are also documented in a monitored provincial database.
An oversight committee also analyzes errors or “near misses” that can occur in a hospital setting, but even with all of the monitoring and eyes on staff, dangers have persisted.
“Our whole goal is to get that partnership with families,” said director of nursing Valerie Diabo. “So getting families, getting community members on some of our committees, that’s always been one of our goals, is to involve the community more to see the work that goes into it, and to be part of it.”
The pandemic revealed a somewhat surprising statistic: a significant decrease in falls.
“That could be due to the fact that our residents didn’t have to move that much, like walking around the units and doing multiple transfers,” said Sananikone.
Aside from falls, the stats didn’t really change pre-pandemic to pandemic, but access was so limited, cultural coordinator Calvin Jacobs was not able to introduce incoming staff to local culture – who often come from various outside agencies.
“Every new employee goes through an orientation that includes training with Calvin. So, yes, the employees get appropriate sensitivity training. However, this fell during COVID as a result of several factors but mostly time,” an email from the KMHC board to THE EASTERN DOOR reads.
Of the 245 KMHC employees, 166 are Native.
A number of new measures were implemented during the pandemic, like a 9 a.m. daily COVID update amongst staff that helped to keep patients safe as well. Staff symptom logs initiated during the pandemic are likely here to stay, Sananikone said.
“Families have a right when there’s an incident and there’s different ways of reporting,” said Westaway. “You could have an event that occurs within the organization, like an incident or an accident, and that gets documented on a form, it goes through a process and ends up in Mendy’s hands, and it’s analyzed and there’s an action plan put in place, and then there’s always a retroaction with the family.
“Sometimes, though, we might not be advised of it, and an event we might not be advised about doesn’t get documented. For whatever reason, it’s missed,” she said.
“So what we ask a family member to do, or a visitor if they witness an event, is to go right away to a staff member or the manager so that the manager can investigate and document,” said Westaway.
If unsatisfied, a formal complaint could be the next step.
KMHC is in the midst of putting out a call for a complaints commissioner to have someone who is fully dedicated to these issues, which sets out specific recourse.
While they wait for an arms-length commissioner, the complaints commissioner of the CISSS de la Montérégie-Ouest will field calls or emails once a complaint is first sent to Westaway.
Diabo said when a complaint comes in they see it as an opportunity to improve.
“It gives us an opportunity to investigate it to look if it’s valid, or is it not valid. And we always learn something from a complaint,” she said. “We don’t look at that complaint as a bad thing. We look at it as an opportunity for us to improve our services.”
A recent change to the complaints process in the KMHC policy is the ability to remain anonymous to the person you are submitting a complaint about, including workers at the hospital, which may encourage more people to speak out about issues that need to be addressed.
Near misses have a separate auditing system to help keep track of them.
“We make an error before it even gets to the resident and we say ‘What did we do, how did we catch it?’” said Diabo. “What do we need to change? It’s reported as a near miss and then we get to analyze it right away and change if we need to change, so that near miss doesn’t end up being a miss.”
Eastern Door Editor/Publisher Steve Bonspiel started his journalism career in January 2003 with The Nation magazine, a newspaper serving the Cree of northern Quebec.
Since that time, he has won numerous regional and national awards for his in-depth, impassioned writing on a wide variety of subjects, including investigative pieces, features, editorials, columns, sports, human interest and hard news.
He has freelanced for the Montreal Gazette, Toronto Star, Windspeaker, Nunatsiaq News, Calgary Herald, Native Peoples Magazine, and other publications.
Among Steve's many awards is the Paul Dumont-Frenette Award for journalist of the year with the Quebec Community Newspapers Association in 2015, and a back-to-back win in 2010/11 in the Canadian Association of Journalists' community category - one of which also garnered TED a short-list selection of the prestigious Michener award.
He was also Quebec Community Newspapers Association president from 2012 to 2019, and continues to strive to build bridges between Native and non-Native communities for a better understanding of each other.