All long-term care homes in Ontario are governed by one piece of legislation: the Long-Term Care Homes Act, 2007 (LTCHA) designed to help ensure that residents of long-term care homes receive safe, consistent, high-quality resident-centred care. The Ontario Regulation 79/10 (Regulation) is made under the LTCHA and provides additional requirements.
Section 53 of the Regulation sets out the requirements relating to the care for residents with “Responsive Behaviours,” which are defined as signs and symptoms of disturbed perception, thought content, mood, or behaviour. They include agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep problems, wandering, and a variety of socially inappropriate behaviours. One or more symptoms will affect nearly all people with dementia over the course of their illness. Although cognitive symptoms are the hallmark of dementia, responsive behaviours often dominate both the presentation and course of the disease, creating the most difficulties for people with dementia and their caregivers.[i]
Section 54 of the Regulation sets out the requirements relating to – “Altercations and Other Interactions between Residents” and says steps must be taken to minimize the risk of altercations and potentially harmful interactions between and among residents.
Furthermore, and more tellingly, section 19 (1) of the LTHCA – “Duty to Protect” says:
Every licensee of a long-term care home shall protect residents from abuse by anyone and shall ensure that residents are not neglected by the licensee or staff.
By saying anyone, LTC home administrators may interpret this to include other LTC residents.
In my opinion, the interpretation of the potential legal repercussion of aggressive altercations between LTC residents as a result of responsive behaviours has resulted in a reluctance to admit seniors with a history of responsive behaviours into LTC. For example, the Behavioural Assessment Tool used to evaluate prospective LTC admissions describes the frequency and types of responsive behaviours over the last three months, but then adds a request to document if there were any concerning behaviours present in the last 12 months. In my experience, LTC homes are using this question to justify declining requests for admissions, even if responsive behaviours have improved with treatment. Furthermore, evidence-based medicine reveals that responsive behaviours can respond to treatment in 2 to 3 weeks, yet LTC homes commonly demand stability of hospitalized patients for at least 3 months before they are allowed to enter into the LTC system as a new resident. This arbitrarily places unnecessary obstacles in the way of community members from entering LTC. For hospitalized patients, these barriers result in prolonged lengths of stay in hospital, which in turn limits the availability of beds for other patients.
In my experience, these stipulations are also being erroneously applied to hospitalized patients whose responsive behaviours arose as a consequence of delirium due to acute illness. These patients are incorrectly labelled as having responsive behaviours, mandating 3 additional unnecessary months of stability before discharge, and having responsive behaviours red flagged on their files for up to 12 months, thus potentially biasing LTC homes against accepting them into LTC.
It appears that the interpretation of section 19 (1) has resulted in the LTCHA failing to meet its mandate to meet the care needs for seniors with dementia and responsive behaviours and is another example of a limitation in legislation.
[i] Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. The BMJ, 350, h369. https://doi.org/10.1136/bmj.h369