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Intervention reports are produced only for the health and social services sector, in accordance with the Act respecting the Health and Social Services Ombudsman, which authorizes the Québec Ombudsman to intervene of its own initiative if it believes a person or group of people has been or may likely be wronged by an act or omission:
The Québec Ombudsman:
In May 2011, the Québec Ombudsman received a report concerning the quality of care and services provided at Centre d'hébergement et de soins de longue durée Saint-Lambert-sur-le-Golf. When the investigation was completed, it made recommendations to the residential and long-term care facility notably aimed at:
The institution informed the Québec Ombudsman that its recommendations had been approved and were in the process of being implemented.
In June 2012, the Québec Ombudsman received a report concerning Ressource intermédiaire de la Montagne, which had opened on May 28, 2012. According to the report, the facility was ill-prepared to admit the residents when it opened. The report denounced:
The investigation showed that the quality of the living environment was affected by the fact that amenities were basic at best and there were no recreational and social activities. Furthermore, there was some confusion as to the respective roles of the CSSS and Ressource.
The Québec Ombudsman made recommendations to Ressource and the CSSS aimed at solving these problems. They informed the Québec Ombudsman that its recommendations have been approved and were being implemented.
The Québec Ombudsman received a report about Centre d’hébergement Vincenzo-Navarro denouncing gaps in supervision, the staff’s lack of training and skills, and inappropriate use of means of restraint. While the Québec Ombudsman was investigating, it received a second report, this one regarding signs of negligent nursing care. The investigation conducted by the Québec did indeed expose worrisome facts about supervision of the residents, the care provided to them, and the staff’s approach. The Québec Ombudsman made five recommendations to the residential centre. Given that almost all the places there are under purchase agreements with the Agence de la santé et des services sociaux de Montréal, the Québec Ombudsman also made a recommendation to the Agency, namely, that it take measures to ensure the quality of the care and of the living environment provided to the residents. Both the residential centre and the Agency let the Québec Ombudsman know that its recommendations had been approved and were in the process of being implemented.
In March 2012, the Québec Ombudsman received three reports of concerns regarding the quality of care and the living environment of residents at Hôpital Ste-Monique. Its investigation focused on the physical state of the premises, the delivery of nursing care and assistance, the quality of the food and the attitude of staff and management toward residents and their families. While the Québec Ombudsman found no deficiencies with regard to service quality, it is of the opinion that the hospital must implement its construction project to improve residents’ living conditions. Given the announced project funding and the general purport of its findings, the Québec Ombudsman is not making any recommendations.
In February 2012, the Québec Ombudsman intervened on its own initiative in the case of two intermediate resources under contract with Centre jeunesse de Montréal – Institut universitaire (CJM-IU). The investigation focused on:
The Québec Ombudsman’s investigation revealed that the children under the resources’ care were the victims of the deficiencies in service organization. However, the Québec Ombudsman acknowledges the corrective measures taken by the Centre jeunesse de Montréal and its firm commitments to review its practices. The Québec Ombudsman is satisfied with the actions taken or planned in the short term.
In September 2011, the Québec Ombudsman was informed that a user who had been confined in an institution (Hôpital Louis-H. Lafontaine) was kept isolated in her room all the time apart from short periods that could be cancelled if she exhibited bad behaviour.
The investigation by the Québec Ombudsman focused on application of the user’s therapeutic plan, use of means of restraint, and implementation of the treatment order. The conclusions reached by the local service quality and complaints commissioner in her report alongside this investigation were the same as those of the Québec Ombudsman. She recommended that the institution:
As for the delay in implementing the treatment order, the Québec Ombudsman recommended that the institution:
The institution let the Québec Ombudsman know that it agreed with its recommendations.
The Québec Ombudsman received a report about the obstetric services provided by the Centre de santé Inuulitsivik, in Nunavik. The main bone of contention was that the Inuit women of Kuujjuarapik have to use a midwife within their community but would rather have a doctor-assisted birth in Montréal.
In the course of the investigation it conducted, the Québec Ombudsman talked with health professionals in the North and examined medical treatment data. It found that birthing occurred under perfectly safe conditions and the statistics on mother and child health were particularly reassuring. However, the Québec Ombudsman nonetheless recommended that the Ministère de la Santé et des Services sociaux immediately make good on a commitment written into the Politique ministérielle de périnatalité 2008-2018, namely, that the Department work with the Nunavik and Terres-Cries-de-la-Baie-James health and social services network to determine aims and objectives tailored to the Inuit and Cree population.
The MSSS pledged to take the necessary steps to do this and to send the Québec Ombudsman a copy of these aims and objectives as soon as the process was completed.
In May 2010, the Québec Ombudsman was advised of the death of a user of Résidence Parc Jarry’s intermediate resource section. The facts related to an event that occurred in December 2009: the man was found dead on the floor of his bedroom. According to the information gathered, an orderly had deliberately failed to provide the necessary supervision of someone whose condition required constant monitoring. At the end of an investigation of the corrective steps taken by the institution following the event, the Québec Ombudsman deemed that all reasonable means had been put into place to better ensure the safety of residents and to establish adequate mechanisms of communication. Note, among other things, that the institution fired the orderly. The Québec Ombudsman made no recommendation to the institution.
The report received concerned the quality of care and services delivered by the Centre d’hébergement Andrée-Perrault. After investigating, the Québec Ombudsman noted that only some of the guiding principles of the Department’s orientations regarding quality living environments were being implemented. The main shortcomings involved communication, maintenance of functional independence, cognitive stimulation, and the concept of "living environment." The Québec Ombudsman’s recommendations were aimed at various ways of improving the slate of services to users, whether drafting of an intervention plan for every resident, assignment of a system navigator, assistance with meals, upkeep of equipment, recreational and stimulation activities, and work organization better paced to the client population. The authorities in question informed the Québec Ombudsman that they intended to act on its recommendations.
Following the death of a Centre d’hébergement Champlain Marie-Victorin resident in November 2011, the Québec Ombudsman intervened on its own initiative to assess residents’ safety and the quality of services, particularly in the prosthetic unit for seniors with severe cognitive impairments. The Québec Ombudsman’s recommendations were aimed at the residence applying the various improvement measures already defined in its in-house action plan and framework program. Ongoing monitoring of the quality of all services is also necessary. The Québec Ombudsman’s recommendation to the Agence de la santé et des services sociaux de Montréal was that it ask the Department for a new quality assessment visit of the residence. The authorities concerned briefed the Québec Ombudsman on the actions taken or planned with a view to following up its intervention report, to its satisfaction.
The Ombudsman received a report concerning the quality of care, services and living conditions provided to residents of the Villa Sainte-Anne intermediate resource attached to the CSSS de Dorval-Lachine-LaSalle. The Ombudsman made recommendations to the intermediate resource, the CSSS to which the resource is attached and the Agence de la santé et des services sociaux de Montréal. The recommendations mainly dealt with the implementation of concrete improvement measures, the continuing assessment of results achieved and the improved supervision of the resource by the responsible bodies, according to their respective missions.
In light of the intervention report, the institution is finalizing its response in order to follow up on the recommendations.
Since 2008, the Québec Ombudsman has received complaints about the emergency unit at Hôpital régional de Saint-Jérôme on a regular basis. Recommendations and their implementation notwithstanding, users continue to be dissatisfied with various aspects related to care, staff and delays.
The recommendations contained in this report are meant for the health and social services centre and are aimed primarily at user safety, nursing staff responsibilities, information to users waiting to be seen, triage per se, training, evaluation of practices, and deployment of human resources.
The institution made it clear to the Québec Ombudsman that it intended to implement all of its recommendations. The Québec Ombudsman will remain watchful.
The Québec Ombudsman intervened on its own initiative in response to a tragedy (death of a father and two of his children) involving a family that had received services from Centre Jeunesse de la Mauricie et du Centre-du-Québec for more than two years. The main thrust of the Québec Ombudsman’s findings is the importance of conducting an independent and unbiased case review further to any incident that casts doubt on the ability of the institution to carry out its mission. The Québec Ombudsman therefore recommended that the youth centre make these reviews standard practice under such circumstances. In the wake of these events, the youth centre had decided to commission a service quality improvement specialist to examine operations and propose ways of bettering them. One of the Québec Ombudsman’s recommendations is that these proposals be implemented. The institution had also taken measures to have this happen.
The report emphasizes the disorganization surrounding the closing and postponing of the closing of Foyer Le Cardinal inc., an intermediate residential resource for six young people aged 10 to 15 with mental health problems. The Québec Ombudsman’s investigation showed that the residents were affected by the lack of coordination and communication between the two parties in question, i.e. the youth centres and the residential resource. The inadequate planning caused the young residents anxiety.
The Québec Ombudsman’s recommendations to Les Centres jeunesse de Lanaudière were that future closings be planned:
When the new home support reference guide came into effect, many users saw their services reduced. They complained that they were caught off guard, did not get the required information or support, and saw no measures for ensuring service continuity. They also questioned the effectiveness of the institution’s complaint examination procedure.
The purpose of the improvements that the Québec Ombudsman recommended to the health and social services centre is to prevent the occurrence of similar situations. The recommendations mainly concern:
The centre made it clear to the Québec Ombudsman that it intended to implement all of its recommendations. The Québec Ombudsman has asked to be informed about the measures taken to do so and will remain watchful.
Between December 13 and 23, 2010, that is, in fewer than 10 working days, 60 seniors with decreasing independence, most of them from Hôpital Pierre-Le Gardeur, were transferred to the Centre multivocationnel Claude-David’s transitional unit.
The incident as reported to the Québec Ombudsman concerned:
The Québec Ombudsman made recommendations to the CSSS du Sud de Lanaudière, the Agence de la santé et des services sociaux de Lanaudière, and the Ministère de la Santé et des services sociaux (MSSS). They mainly concern follow-up on the CSSS’s existing action plan to improve service quality. On a broader basis, the Québec Ombudsman also examines the pressure on institutions to unclog emergency services, which was what was behind the transfers: the solutions contemplated regionally and by MSSS must first and foremost respect users’ safety and well-being.
The authorities concerned assured the Québec Ombudsman of their complete collaboration in implementing the required solutions, some of which, they pointed out, had already been applied.
The Québec Ombudsman intervened on its own initiative concerning Lakeshore General Hospital’s emergency department, more specifically, safe care and services to users. The Québec Ombudsman’s recommendations were aimed primarily at greater monitoring of Lakeshore General Hospital emergency department users and additional guarantees as to dignity, confidentiality and safety. The Québec Ombudsman also recommended that the West Island Health and Social Services Centre (CSSS) inform it of the action plans established in order to achieve the goals identified. The CSSS briefed the Québec Ombudsman on the various means undertaken or planned in order to follow all its recommendations, to the Québec Ombudsman’s satisfaction.
The Québec Ombudsman received a report denouncing problems at Maison de thérapie et de réinsertion sociale L’Inter-Mission. After investigating, the Québec Ombudsman issued recommendations to the business (9206-9343 Québec inc.) that operates L’Inter-Mission. The recommendations dealt mainly with certain administrative procedures, residents’ assessment and recourse, medication management, first-aid equipment, residents’ supervision and safety, and storage of illicit substances and prohibited items. The body in question briefed the Québec Ombudsman on what it had done to rectify the deficiencies noted. The various initiatives satisfied the Québec Ombudsman.
The Québec Ombudsman received a report calling for it to intervene regarding the Centre de traitement des dépendances Toxi-Co-Gîtes and its facilities (transitional houses). The Québec Ombudsman’s recommendations concerned the information the institution provides about its service offering, residents’ safety and rights, certain administrative practices, information to new employees and to volunteers, and the physical premises. The body in question briefed the Québec Ombudsman on what it had done to rectify the deficiencies noted. The various initiatives satisfied the Québec Ombudsman.
The Québec Ombudsman received a report calling for it to intervene regarding the Centre de thérapie Manoir Aylmer and its facilities (transitional houses). The main problems concerned care and service quality. The Québec Ombudsman’s recommendations were intended for Toxi-Co-Gîtes 2003 inc., which operates Manoir Aylmer. The recommendations had to do with the information the institution provides about its service offering, certain administrative practices, residents’ safety and recourse, medication management, storage of illicit substances and prohibited items, and the physical premises. The body in question briefed the Québec Ombudsman on what it had done to rectify the deficiencies noted. The various initiatives satisfied the Québec Ombudsman.
The Québec Ombudsman received a report calling for it to intervene regarding Maison l’Intégrale, owned by 9179-2143 Québec inc. The main problems concerned care and service quality. The Québec Ombudsman’s recommendations were intended for 9179-2143 Québec inc., the business that operates Maison l’Intégrale. The recommendations had to do with the procedure for admitting new residents, certain administrative formalities, recourse for residents, and storage of illicit substances and prohibited items. The body in question briefed the Québec Ombudsman on what it had done to rectify the deficiencies noted. The various initiatives satisfied the Québec Ombudsman.
The Québec Ombudsman received a report calling for it to intervene regarding he Centre de traitement de dépendances Domaine Orford. The main problems concerned care and service quality. The Québec Ombudsman’s recommendations are intended for Toxi-Co-Gîtes 2003 inc., which operates Domaine Orford. The recommendations had to do with the health questions asked in admitting new residents, certain administrative formalities, guarantees as to the confidentiality of personal information, compliance with court orders, residents’ recourse and safety, and storage of illicit substances and prohibited items. The body in question briefed the Québec Ombudsman on what it had done to rectify the deficiencies noted. The various initiatives satisfied the Québec Ombudsman.
The situation reported concerns the problems encountered by a person who asked the adoption and reunion service of Centre jeunesse de Québec – Institut universitaire to search for her birth father, i.e. the processing times and the improper disclosure of information regarding her request (results, location of her parent).
The Québec Ombudsman's recommendations to the youth centre are aimed at:
A CSSS service user who filed a report concerning complete or partial service cuts further to the new normative framework for home support services said that users were caught off guard and were not given the assistance or information they needed, and that no measures were taken to ensure service continuity.
The Québec Ombudsman’s recommendations, intended for the CSSS and the agency to which it reports, were aimed in particular at eliminating an exclusion criterion deemed not to comply with the ministerial home support policy, namely, that services only be provided to people who live alone or with someone who cannot help them because of their own disabilities. The other improvements recommended by the Québec Ombudsman – information, impact assessment, transitional measures, system navigator – were aimed at preventing the occurrence of similar events.
The authorities concerned informed the Québec Ombudsman that the regional normative framework had been revised as it had suggested and that it could rely on them to implement its recommendations.
A community organization in the Québec City region asked the Québec Ombudsman to examine an Agence de la santé et des services sociaux de la Capitale-Nationale decision that did not appear to comply with the Politique de reconnaissance et de soutien des organismes communautaires de la région de Québec and the Programme de soutien aux organismes communautaires of the Ministère de la Santé et des Services sociaux. The organization argues that the Agency does not correctly interpret the definitions used to categorize the different kinds of community organizations, which affects subsidy amounts.
Following the Québec Ombudsman's intervention, the Agency admitted that not everyone understands or interprets the criteria for determining community organization typology the same way. It therefore committed to discussing this issue with the representatives of the region's Regroupement des organismes communautaires.
A report was made because a user:
The Québec Ombudsman recommended that Centre Notre-Dame de l'Enfant henceforth obtain the informed consent of users with an intellectual disability in all situations involving a significant change in their life project.
The facts: A report was received, criticizing the living environment and the quality of the services offered by the residence. The principal grounds for dissatisfaction were the poor food service, the fact that residents were not represented on the institution's board of directors, and management's failure to listen to and respect the residents.
The Québec Ombudsman's recommendations were intended variously for the residence's authorities, the Health and Social Services Agency and the Société d'habitation du Québec, according to their missions. The goal of the recommendations was to improve service quality through:
The Québec Ombudsman has asked the three parties concerned to inform it of the measures implemented in the wake of its recommendations.
The facts: Three babies were victims of violence or family negligence.
The Québec Ombudsman's recommendations were to:
The facts: A report criticized the poor quality of services and care in a seniors' residence, including:
The Québec Ombudsman's recommendations concerned improvements to the layout and maintenance of the premises.
The facts: A report alleged that people with intellectual disabilities were often victims of discrimination based on their handicap, during end-of-life care.
The Québec Ombudsman's investigation did not find evidence to support the facts as reported, and no recommendations were made.
The facts: A report was received to the effect that a resident had died as a result of serious burns (accidentally fell into a bath full of overly hot water and remained there for an extended period).
The Québec Ombudsman's recommendations were intended for the Ministère de la Santé et des Services sociaux, the Agence de santé et de services sociaux de Montréal, the CHUM (Hôtel-Dieu) and the Manoir-de-l'Ouest-de-l'Île Residential and Long-term Care Centre. Their purpose was to ensure that appropriate remedies and measures were introduced to avoid any repetition of the incident.
A petition was sent to the Québec Ombudsman, demanding the removal of the residence's board of directors. The petition had been drawn up by Manoir des Pommiers residents and was signed by 200 people. According to its authors:
The Québec Ombudsman's recommendations were intended for the Manoir des Pommiers, the Agence de la santé et des services sociaux du Bas-Saint-Laurent and the Société d'habitation du Québec. They included the introduction of various measures to solve internal conflicts, ensure better management of the residence and the services provided, and implementation of follow-up actions.
The facts: A report questioned the quality of the services available to users.
The Québec Ombudsman's recommendations were to:
The facts: A report was received to the effect that a person had been kept in the hospital against his will. The report also mentioned a failure to respect deadlines for preventive custody, the use of isolation without valid grounds, bribery to obtain personal clothing, the right to leave the hospital, and exclusion of the person from the process of identifying the care required.
The Québec Ombudsman's recommendations concerned the introduction of various measures to ensure that users' rights were upheld: reminders for personnel, training sessions, stringent application of current legislation and standards, administrative adjustments and a review of the institution's code of ethics.
The facts: A report criticized the conditions of admission to the Jean-Talon Hospital emergency room for people with mental health disorders:
The Québec Ombudsman found that the problems identified had been addressed in a satisfactory manner, and no recommendations were made.
The facts: A report criticized the poor quality of care and services given to three residents in the Manoir Saint-Amand transitional unit.
The Québec Ombudsman's recommendations concerned better oversight of residents: appropriate reminders for personnel, training, tighter controls on residents' safety, especially with respect to movements and medication, a more rigorous process to establish treatment plans, and better supervision of clinical practices.
The facts: A report mentioned numerous deficiencies in the care and services given to residents.
The Québec Ombudsman concluded that some of the allegations were founded. Its recommendations concerned the introduction of measures to improve the quality of the staff-resident relationship, better compliance with standards of professional ethics, more staff training, better supervision of clinical acts and greater attention to clients' needs when planning meals.
The facts: The author of a report feared that some of the Centre's clients were being badly treated, and also alleged over-use of containment and overmedication.
The Québec Ombudsman's investigation did not confirm the facts, and no recommendations were made.
Intervention Report—Contract between Hôpital du Sacré-Coeur de Montréal and Centre de chirurgie et de médecine Rockland MD
Intervention au Centre hospitalier Robert-Giffard/Institut universitaire en santé mentale - pour le Centre « Le 388 »