Long term care home

By Trevor Greenway

Aline Maisonneuve wasn’t given a bath for over two weeks while under the care of nurses at the Villa des Brises long-term care home in Gatineau, a report by Quebec’s complaint commission suggests. 

Quebec’s Commissioner for Complaints and Quality of Services found that the Masham senior, who died April 14, 2024, two days after being found unresponsive in her long-term care room in Gatineau, was the victim of “physical and organizational abuse through negligence” by staff at the care home and the CISSS de l’Outaouais home support (SAD) clinical team. 

Before she was taken to the Hull Hospital, witnesses reported hearing her scream throughout the night – screams that went unanswered. She was then found unconscious and taken to hospital, where she later died two days later. Doctors at the Hull Hospital found bed sores on her back and torso. A coroner is now investigating the circumstances of her death. 

While the details around how her mother-in-law was treated at the home are devastating to read, Shelley Langlois told the Low Down that after waiting for answers for over a year, she and her husband, Guy, feel that someone is finally listening to their heartbreaking story. 

“We feel validated,” said Langlois, flipping through the commissioner’s report. “Validated that our concerns were warranted. None of this felt right from the beginning.”

In his report, Commissioner John Benoit noted that on the day Maisonneuve was found unconscious, paramedics discovered a “clean bandage” on her arm, indicating that she had recent bloodwork done. But medical records showed that she had only received bloodwork on March 27, 2024 – 16 days before she was found unresponsive in her care home room. 

“They asked the staff about this, and they had no record of [Aline] having had bloodwork. We can only deduce that the bandage is from bloodwork that would have been taken during a hospitalization at Hull Hospital on March 27, 16 days ago,” Benoit wrote in his report. “As the bandage was clean, it indicates that [Aline] had not likely been bathed in over two weeks. 

The report referred to Maisonneuve’s treatment plan at the care home between Feb. 27 and March 31, 2024, and noted that, while she received personal hygiene assistance almost every day, “she never received a full bath in the bathtub/shower over the same period” according to her treatment plan. 

“I therefore find that there were shortcomings, not only in terms of assistance with hygiene care by VDB [Villa des Brises] staff, but also in terms of the clinical follow-up provided by the nurses of the home support clinical team working at VDB.”

The report went on to note that Aline was also “fully dressed” upon her arrival at the Hull Hospital, which Benoit wrote, “suggested to us that either she had slept in her clothing or someone dressed an unconscious woman prior to sending her by ambulance. Either scenario is deeply upsetting.” Benoit also noted that he has “doubts about the assistance offered” to Maisonneuve between April 1 and 12, 2024, as the care home has yet to submit her treatment plan for that timeframe, “despite several attempts to obtain it.” 

Staff failed to follow ‘rule of care’

Nurses at the care home noted in their file on April 9, 2024, a few days before Maisonneuve was transferred to hospital, that no pressure ulcers were found on her body, according to the report. However, the report referenced a “lack of detailed notes” on Maisonneuve’s file, especially in the days leading up to her admission to the hospital. Benoit wrote in his report that the discrepancies make it impossible to explain the bedsores found by doctors at the Hull Hospital. 

The report stated that notes from a triage nurse at the emergency room at the Hull Hospital did not indicate wounds found on Maisonneuve when she arrived on April 12, 2024. However, a complete physical examination was not performed in the emergency room. It wasn’t until 9:30 p.m. that night when a doctor and a charge nurse discovered bruises and a pressure sore on her tailbone and back. 

“I am concerned about the health condition observed by the nursing and medical team at the Hull Hospital when your mother was admitted on April 12,” wrote Benoit. “The incomplete record-keeping, the absence of the treatment plan for the period from April 1 to 12, the inadequate use of various documentation and follow-up tools, such as the assessment of the risk of falling and the risk of developing pressure ulcers, and the lack of follow-up on care protocols (e.g. post-falls) demonstrate major shortcomings in the care provided to your mother during her stay at the Résidence Villa des Brises.” The report also described four separate instances when Maisonneuve fell at the care home, and each time staff failed to follow the “rule of care,” which involves post-fall assessments and documentation. According to the report, these post-fall assessments were either “absent or incomplete” and documentation was “very limited.”

The report came with a lengthy list of recommendations and an action plan for Villa des Brises to follow. These include implementing assessment and follow-ups for users who have fallen, ensuring nursing staff are trained in delirium detection, ensuring that nurses include prevention-related clinical guidelines when the risk of pressure sores is identified and several other measures. According to the report, many of these recommendations have been implemented since last summer. 

‘We read it and were just bawling’

Langlois told the Low Down that she and her husband had felt abandoned by the system: nurses and staff at Villa des Brises; executives within the CISSS de l’Outaouais; and their own MNA, Robert Bussière, who has yet to contact the family personally. 

They said they’ve waited more than a year for any movement on their file. 

But now that their complaints have been validated, they said they feel confident that justice for their grandmama, mother and mother-in-law will eventually be served. 

Langlois said when she and Guy read in the report that Maisonneuve was “the victim of physical and organizational abuse through negligence on the part of the VDB and SAD care staff during her stay,” they began to weep.

“I highlighted it. We read it and were just bawling,” said Langlois. “What we were looking for was someone to say, ‘You’re not crazy. This place was a shithole.’ And then to follow up with the action plan.”

Langlois praised Quebec’s complaint commission and said that she hopes her and Guy’s story will give others the confidence to push for justice when they feel they or their family have been wronged. 

Guy said he still struggles with the fact that he couldn’t save his mother from neglect at the care home. 

“We knew something was wrong with that place, but we couldn’t do anything about it,” he said, fighting back tears. “We couldn’t save her.” 

MNA Bussière refused to comment on the case, citing that it was a confidential matter. 

A coroner’s report into Maisonneuve’s death is expected to be finalized in June.