Sex, lies and audiotape

Was the nursing home scandal in Quebec an isolated
incident or a Pandora's box of institutionalized abuse?

By Giancarlo La Giorgia

It all started with 90 hours of audiotape. By the end of those two weeks in November, suicide, prostitution and beer had been thrown on the pile, taking the story from media circus to an all-out exposé on the conditions in nursing homes in Quebec. The scandal, involving patient abuse by workers at St Charles Borromée Hospital, a 200-resident long-term care facility in downtown Montreal, was first aired by Radio-Canada, the French arm of the CBC. Hospital staff had been secretly recorded verbally and psychologically abusing a 51-year-old woman, severely disabled by a car accident when she was 18 years old. The story was then leaked to the media by the woman's family.

The recordings reveal workers at the public hospital calling the woman "pig," repeatedly telling her to shut up, refusing numerous requests for water and warning her that she would be left in bed all day if she didn't keep quiet. The most offensive incident caught on tape was when two male workers, teasing the patient, told her that someone was outside her window, watching her and masturbating. The hospital's then-director, Léon Lafleur, initially characterized this as "black humour," punishing each of the orderlies with a three-day suspension and subsequently allowing them to resume working on the same floor as the victimized patient.

"I don't think the family or the person herself [found] that particularly humorous," said Dr Philippe Couillard, Quebec's health minister at a press conference after the facts were first publicized.

The woman's sisters say they resorted to hiding a tape recorder in their sister's room last spring and eventually leaking the story to the media because several attempts to get the hospital's administration to investigate her mistreatment failed. Through their lawyer, Jean-Pierre Menard, the woman's family filed a lawsuit against the hospital she had called home for the past 10 years, demanding that its director be fired and that it be put under trusteeship. The woman has since been moved to another institution.

Immediately following the initial revelations of improprieties, the health minister launched a two-week public inquiry into the imbroglio, criticizing the hospital's director for not taking the situation more seriously. Two days later, after a seven-year tenure at the helm of the hospital, Mr Lafleur's body was found in a hotel room in St-Hyacinthe, the result of suicide. In a letter he had written to Montreal paper Le Devoir before taking his life, Mr Lafleur criticized the health minister for not supporting him amid the controversy surrounding his hospital. Nevertheless, the provincial government continued its inquiry, which was concluded on December 9. As a result the hospital was placed under trusteeship for 120 days, until April 6. It is currently being run by interim director Léonard Vincent, a Montreal-area healthcare administrator with 30 years of experience.

This isn't the first time that St Charles Borromée has faced criticism, nor is this the only case of abuse to have come to the government's attention. In 1994, the Canadian Council on Health Services Accreditation reviewed the hospital and found that its services were not up to standard. A public inquiry at the time led to the revelation of two patients' allegations of sexual abuse, the dismissal of the then-director and the appointment of Lafleur to the top position.

In response to the latest incident, Dr Couillard has stated that "there are other cases and we are aware of them." A hospital spokesperson confirms that other investigations are currently underway. Hubert Dupont, a former patient recovering from meningitis, held a press conference last month alleging he lost the use of his legs after being bedridden for three months because hospital staff confiscated his walker.

Most people in Quebec's healthcare sector, including employees at St Charles Borromée, say they were as shocked as anyone else when they heard about what was going on there -- although one nurse's response was reportedly "why don't they ask them about the beer and prostitutes?" Solidarity with the hospital's staff notwithstanding, some were willing to offer their opinions on mistreatment within nursing homes. "It would be foolish to think that there is no abuse in our establishments," says Dr Michel Bouffard, executive director of Notre-Dame de la Merci Hospital, a 612-bed public facility in Montreal. "Abuses happen -- just as they do in society."

Dr Bouffard believes that one of the factors contributing to patient mistreatment is the fact that "many caregivers have not received what is, from my point of view, adequate preliminary training." Most orderlies receive just 70 to 100 hours of training, he says. "When you consider that these people spent at least seven or eight hours a day with patients who are severely disabled and extremely demanding, you realize that their training is insufficient."

Likewise, Dr Pierre Sylvestre of the Louis Riel Centre, also in Montreal, sees the problem of both patient and employee dissatisfaction as being inextricably linked to a lack of resources. "Realistically, there should be many more healthcare workers at nursing homes," he says. "But it isn't just about healthcare -- this is a place where people live, where they will live the last days of their lives so there is a need for organized activities and social relationships." Dr Sylvestre stresses the importance of understanding how patients like his, who are struggling with both a loss of autonomy and a dependence on strangers, are very vulnerable and are therefore "people whose rights must be respected."

According to Dr Bouffard, the insecurity resulting from diminishing self-sufficiency often presents a challenge to nursing home administrators trying to tackle abuse because the patients are easily intimidated and afraid to come forward. He says one of the great challenges is "to make people trust in the extensive system that deals with complaints," as opposed to using the media to air grievances.

While no one questions the fact that the recent complaints warranted an inquiry, some healthcare authorities have wondered at the amount of publicity given to them. André Côté, the director of an association of 40 public and private long-term care centres in Montreal, claims that out of all the complaints his organization receives in a year, the amount of incidents he would qualify as serious are "in the low 10s, if that." He insists that most complaints are related to the difficulty of adjusting to life in a nursing home or accessing certain services in a timely manner, as opposed to problems with an employee's conduct.

When asked about his organization's policy on patient abuse, Mr Côté; says that, as a group, Quebec's nursing homes maintain a zero-tolerance policy toward patient abuse. "But at the same time, there are all sorts of cases that must be evaluated individually." So how did the employees at the eye of the recent media storm walk away from their actions with what amounts to a slap on the wrist?

Dr Bouffard clarifies Mr Côté's position. "When we invoke the term 'zero-tolerance,' it means we don't accept any inappropriate conduct. As for the punishment, we take into account the seriousness of the act, the testimony of witnesses and the past history of the employee. The sanction must be proportional to the action, but it must also be placed in what is considered a fair context." However, reaching a consensus on what constitutes fair punishment in Canada's most unionized province isn't easy. To complicate things, about 70% of Quebec's 143 long-term healthcare centres -- the permanent residences of about 20,000 elderly and disabled adults -- are privately run and, to date, largely unregulated. But not for much longer, if the health minister has his way.

"We are working right now on tabling a bill by June that would change the way we work with the private care centres, possibly through inspections or licenses, we're not sure yet," says Cathy Rouleau, Dr Couillard's press attaché. "Right now we don't have many powers over private facilities, so we plan to make legislation changes in the coming year," she says. Dr Couillard has repeatedly called the present regulation of private long-term care facilities, put in place by the previous Parti Québécois government, "non-functioning." Currently, the regional review boards' only means of evaluating a private nursing home is if the facility's administrators volunteer for it to be inspected.

In lieu of waiting for the new legislation to be passed through, Ms Rouleau says the health minister has committed a team of experts to make 4,000 visits to long-term care institutions across the province, starting at the end of January, "to show people that we are concerned." "We were planning this even before the St Charles Borromée incident happened, this put it on the fast-track." She says the health ministry wants people to understand that "the system is run by humans and humans aren't perfect.... We don't want to have to wait until the end of another inquiry to take action."

Most of the province's healthcare community have been supportive of the health minister's decisions since the St Charles Borromée incident began. As a director of a public nursing home, Dr Bouffard is very pleased by the fact that Dr Couillard "seems to be more in-tune with the need for investment in nursing homes," whereas for at least the past 10 years, "the awareness among health ministers of the very existence of long-term healthcare centres has not been obvious."

"We're crossing our fingers that there is a growing sensitivity to the issue," he says. "With the aging population, there will be a considerable effect on nursing home residency so, barring an increase in funding, we need to know what kind of alternatives can be developed by the Ministry of Health to make sure nursing homes remain a last resort."