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Critical Issues facing Older Adults with Mental Illness : Case Examples Judith A. WahlAdvocacy Centre for the Elderly www.acelaw.cawahlj@lao.on.ca

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Case 1 – Ms. Castro • Ms. Castro is a 56 year old single woman currently living with her elderly father (92)

whom she has supported for 20 years. She previously worked as a cleaning personal until five years ago but now they are supported informally by a cousin in London. Formal supports include PSW support 45 minutes per day 7 days per week.

• Ms. Castro has been functionally declining in her IADLs and ADLs and unable to look after her father as previously. There is evidence through an OT assessment of functional impairment and significant risk for safety.

• Long-term care papers have been started for Ms. Castro, however her father is the SDM and there is a question as to his capacity and understanding as he frequently switches back to Italian and does not seem to appreciate and understand the decision of placement.

Reason for Referral• Referral to the Geriatric Mental Health Program occurred after an incident in which

Ms. Castro took her father out in the middle of the night and drove out of town and ran out of gas. She was found to be disoriented, confused and dressed only in her night clothes. She and her father were brought into the nearby local hospital. As a result of this incident her license was revoked. She does have a diagnosis of “Probable Dementia” from 2009. Other diagnoses include Hypertension, high Cholesterol, chronic neck pain from a work related injury.

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Medications• Trazodone 50mg 1 tab PO OD, Gabapentin 300mg 2 caps PO HS, Ramipril 5mg PO

OD, Crestor 10mg PO OD, Glucosamine 500mg 1 tab PO TID, Calcium 500mg 1 tab PO OD. Medications have been recently initiated on blister packaging as compliance was questionable.

Assessment• Ms. Castro has Dementia, severe probable mixed vascular and Alzheimer’s

characterized by moderate to severe short term memory loss with frequent disorientation, confusion, nominal aphasia, anosognosia and frontal lobe impairment. Visual hallucinations are also occurring, with some paranoia associated.

• With her level of impairment and difficulty functioning she is deemed unsafe to stay at home, and is incapable of making care decisions.

• We suspect that she is incapable of making decisions surrounding finances, however she cannot be formally assessed as an outpatient and would need to be assessed at a Schedule 1 hospital. Ms. Castro has limited insight, compromised judgment, and some inappropriate behaviours likely stemming from the frontotemporal damage (She is reportedly sleeping in her fathers bed at night).

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Course of Care• Ms. Castro was treated with a cognitive enhancer to help her functioning as

well as hopefully help her hallucinations. She successfully transferred from home to long-term care without incident within a month of our assessment.

The Behavioral Support Ontario staff were involved to support staff. However after only a few weeks, staff reported several behaviours including: repetitive questioning to staff and other residents who lacking insight would become agitated with her. displayed similar suspicion and paranoia (likely due to hallucinations) and would often retreat to her room. She also displayed physical behaviours due to misidentifying and misinterpreting her environment, as well as having socially inappropriate behaviours which triggered others residents and caused her to retaliate.

• The police were informed after a resident was injured and she was brought on a form to Victoria Hospital. During her stay in hospital, staff noted she was calm, and there were no incidents of physical behaviours or hallucinations.

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• Recreation Specialists consulted while in hospital to provide LTC with a plan for activities to engage Ms. Castro upon her return.

• The LTC home was receptive to receiving Ms. Castro. They implemented several of the strategies provided by our team, however were unable to secure her a private room due to facility constraints.

• However upon return to the LTC environment, staff again noted similar behaviours to those displayed previously again due to her impairment, lack of insight, judgment, ability to communicate and paranoia (she threw hot soup on another resident; she was trying to kiss another resident who pulled away, and then she hit this resident; and again pulling another resident out of bed, this time her roommate who was seriously injuring her).

• Police were again called, and she was placed on a form 1 by the LTC physician, however the police charged her, and took her to the London Police Station. Ms. Castro was granted a 60 day psychiatric leave from the long-term care home.

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• They were informed of her diagnosis, given a list of medications and informed of our program’s involvement. Conditions were placed on Ms. Castro that prohibits her from returning to the LTC home. Ms. Castro was seen in court, and despite staff from our program advocating for an admission to the Psychiatric Intensive Care Unit at Victoria Hospital for further Geriatric Psychiatric assessment and treatment, she was charged with assault and remanded, being then transferred to Elgin Detention Centre in St. Thomas for assessment for 5 days to undergo undergo forensic assessment. It was explained that because she was charged and “remanded” instead of “released” the charge supersedes the Form 1 and therefore she cannot be sent to Victoria Hospital and admitted to the PICU because it is not a detention centre. The rationale for this action was that the court could not ensure that she would be held at the hospital and not returned to LTC after the form expired in 72 hours.

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• Upon being transferred to the Elgin Detention Centre, they stated that the Form 1 always supersedes criminal charges and Ms. Castro was sent back to the Victoria Hospital Emergency Department because it is apparent that she has dementia and needs treatment under the Form 1. Ms. Castro required police escort and 24 hour police supervision while in hospital. She remained an inpatient for five weeks. Subsequently she was discharged from the adult mental health inpatient unit at LHSC to the Elgin Middlesex Detention Centre (EMDC). From there she would be transferred to the secure forensic mental Health unit in Milton. Behaviour recommendations were supplied upon discharge from hospital, and Ms. Castro was discharged also from our program.

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• Health Care Consent Act – Who is Decision Maker for Ms. Castro

• Mental Health Act• Long Term care Homes Act- Private Room • Criminal Code • Finances – ODSP? Savings? CPP Disability• Capacity to manage Finances • Fathers finances – OAS/CPP

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1. Finances • Ms. Castro • 56 year old single woman • lives with her elderly father (92) whom she has supported for 20

years. • previously employed as a cleaner until five years ago but now

they are supported informally by a cousin • Team suspect that she is incapable of making decisions

surrounding finances, however she cannot be formally assessed as an outpatient and would need to be assessed at a Schedule 1 hospital

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1A Finances – Capacity • Options if believe not capable for Finances• IF Continuing POA Property

• Look at POA Property document if available – could be in effect already as these are in effect on signature if no terms in it requiring assessment

• If contains requirement for assessment • If specified who is assessor then that person assesses• If no person/ type of person specified – Then Capacity Assessor

• If Inpatient in Psychiatric Facility and no CPOA• SDA section 15 / Mental Health Act S.54• assessment by Physician - results in OPGT being SDM for Property

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1A Finances – Capacity • If anywhere other than inpatient in Psychiatric facility and NO

CPOAP• Trusteeships can be set up for ODSP, OAS, CPP

• Not involve court and no need for CPOAP• Will involve application including info of assessment of incapacity

• SDA S.16 - Statutory Guardianship • Assessment by Capacity Assessor• “he who requests pays” but then asks OPGT to repay fee to

requestor from person’s income• OPGT becomes statutory guardian• Family and others can replace OPGT on application to OPGT (non

court application)

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1B Finances – Sources • Could be eligible for CPP Disability • The Canada Pension Plan (CPP) disability benefit is a taxable

monthly payment that is available to people who have contributed to the CPP and who are not able to work regularly at any job because of a disability. To qualify for a CPP disability benefit, you must:

• have a severe and prolonged disability • be under the age of 65• meet the CPP contribution requirements.

• To qualify for a Canada Pension Plan (CPP) disability benefit, must have contributed to the CPP in:• four of the last six years, or• three of the last six years if you have contributed for at least 25

years.

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1B Finances• Could be eligible for ODSP - Income Support• The Ontario Disability Support Program helps people with disabilities who are in

financial need pay for living expenses, like food and housing.• May qualify for Income Support if :• are 18 years of age or older , live in Ontario• are in financial need, and are found to be a "person with a disability" as defined under

the Ontario Disability Support Program Act.• A person with a disability is someone who has a substantial physical or mental

impairment that: • is continuous or recurrent• is expected to last a year or more.

• And, the physical or mental impairment must directly result in a substantial restriction in the person's ability to:• work• take care of him or herself or• take part in community life.

• The impairment(s), its duration, and the restriction(s) must also be verified by an approved health care professional.

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1B ODSP• To determine if eligible to receive Income Support, MCSS looks at

both financial situation, and disability status.• Financial eligibility• Consider BOTH person's and family's income, assets, housing costs

and the size of your family to calculate if person qualifies financially for Income Support and quantum

• Disability eligibility• Must meet the definition of "a person with a disability" as defined

under the Ontario Disability Support Program Act.

• If receiving Ontario Disability Support Program Income Support, person may also be eligible to receive other benefits and supports:• health benefits, such as prescription drug and dental coverage • disability-related benefits, such as help to pay for hearing aids 14

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1B ODSP• If receiving Ontario Disability Support Program Income

Support, person may also be eligible to receive other benefits and supports:• health benefits, such as prescription drug and dental coverage • disability-related benefits, such as help to pay for hearing aids

• Asset limits• There are limits to the amount of non-exempt assets person can

have and still remain eligible:• for a single person, the limit is $5,000

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1B – Finances - If Ms. Castro had been 60 plus

• Finances available for person 60 plus• OAS and GIS and GAINs• CPP• Allowance (60- 64)if spouse on OAS• Seniors Drug Benefits

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1B - Fees in LTC Homes • Long term care• Fees based on individual income only not assets and not family

income • If NO INCOME still eligible – and LTC home still gets full funding at

basic rate from MOHLTC – LTC home cannot refuse admission based on income

• If not able to pay basic accommodation rate – entitled to rate reductions . LTC home licensee obligated to make application for rate reductions

• If no income must apply for ODSP• Must maximize income - part of application for rate reduction is

prompt to maximize income benefits

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2. SDM for Health Care Decisions

• Long-term care papers have been started for Ms. Castro, however her father is the SDM and there is a question as to his capacity and understanding as he frequently switches back to Italian and does not seem to appreciate and understand the decision of placement.

• Is Father the SDM???????If Father is NOT SDM who is the SDM? • SDM for what?

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2. SDMs for Health Care • Health care includes Treatment ,

Admission to LTC , Personal Assistance services in LTC • An SDM IS the proper SDM ONLY if highest

in Hierarchy AND MEET REQUIREMENTS to be SDM • BOTH are requirements to give authority

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Hierarchy of SDMs 1. Guardian of person2. Attorney in POAPC3. Representative appointed by the Consent and Capacity Board4. Spouse or partner5. Child or parent or CAS (person with right of custody)6. Parent with right of access7. Brother or sister8. Any other relative9. Office of the Public Guardian and Trustee

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SDMs

• List is hierarchical

• All persons on same level have equal right to be SDM (i.e.. all brothers and sisters equally rank)

• Person ALWAYS has SDM if incapable as OPGT is SDM if person has no one higher on hierarchy or if conflict between equal ranking SDMs

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Requirements for Person to be an SDM

The person highest in the hierarchy may give or refuse consent only if he or she is:a) Capable in respect to the treatmentb) At least 16 years old unless the parent of the incapable personc) Not prohibited by a court order or separation agreement from acting as SDMd) Availablee) Willing to act as SDM

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Determination of Capacity of SDM

• Health practitioner MUST determine if person meets requirements to be SDM

• If HP of opinion that SDM not capable by capacity definition (ability to understand and ability to appreciate) then must turn to next highest ranking SDM

• Must make a decision about capacity of SDM

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SDM for what?• Admission to LTC • Who assesses – EVALUATOR ( more people are evaluators than

the CCAC staff) • How to do the assessment – NOT just the 5 question

questionnaire• What if person assessed refuses assessment for admission

• HP can STILL assess capacity • What if person refuses move to LTC home

• refusals are not necessarily indications of decision making capacity • Capable person can make choice but if person incapable, SDM has

authority for decision making • Challenge is managing the admission

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3. Capacity for Treatment and Risk Assessment

With her level of impairment and difficulty functioning she is deemed unsafe to stay at home, and is incapable of making care decisions.

- Risk assessment about living at home – Under SDA? - purpose of risk assessment - Information or evidence for her if she is capable of making decision

about shelter or for her SDM if she is incapable for making decision about shelter

- but no specific other authority related to this risk assessment- part of “evidence” and “information” on which to base a decision

- Capacity for treatment not same as capacity for shelter - Significance is that could be DIFFERENT SDMS as one is hierarchy list

in HCCA and other is either POAPC or Guardian of the Person under SDA

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3. Capacity for Treatment and Risk Assessment

• Mental Health Act s. 15

Form 1 – application for psychiatric Assessment could be on grounds that person “ has shown a lack of competence to care for self” AND physician of opinion that person is apparently suffering form a mental disorder of a nature of quality that likely will results in • Serious bodily harm to the person• Serious bodily harm to another persons • Serious physical impairment

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4. Admission to LTC Home • Ms. Castro successfully transferred from home to long-term care without

incident within a month of our assessment.

• Role of CCAC to determine BOTH eligibility and assist with applications - Fact that person has mental illness not mean that he or she would be ineligible

• When applications made to homes , LTC homes may approve or refuse admission in particular circumstances

• ACE experience • Homes refusing admission for improper grounds• Homes refusing admission without giving details for refusal • MAJOR issue for people with psychiatric disorder/ who have been in the

psychiatric system / who have behaviours that are challenging for care and will require care plans that include specific approaches etc – once admitted care plans as directed not always followed creating other challenges

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LTC Licensee grounds to Withhold Approval LTCHA s. 44

Licensee consideration and approval(7) The appropriate placement co-ordinator shall give the licensee of each selected home copies of the assessments and information that were required to have been taken into account, under subsection 43 (6), and the licensee shall review the assessments and information and shall approve the applicant’s admission to the home unless,

(a) the home lacks the physical facilities necessary to meet the applicant’s care requirements;(b) the staff of the home lack the nursing expertise necessary to meet the applicant’s care requirements; or(c) circumstances exist which are provided for in the regulations as being a ground for withholding approval.

Written notice if licensee withholds approval(9) If the licensee withholds approval for admission, the licensee shall give to persons described in subsection (10) a written notice setting out,(a) the ground or grounds on which the licensee is withholding approval;(b) a detailed explanation of the supporting facts, as they relate both to the home and to the applicant’s condition and requirements for care;(c) an explanation of how the supporting facts justify the decision to withhold approval; and(d) contact information for the Director.

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5. LTC Homes and Responsive Behaviours • The Behavioral Support Ontario staff were involved to support

staff. However after only a few weeks, staff reported several behaviours including: repetitive questioning to staff and other residents who lacking insight would become agitated with her. displayed similar suspicion and paranoia (likely due to hallucinations) and would often retreat to her room. She also displayed physical behaviours due to misidentifying and misinterpreting her environment, as well as having socially inappropriate behaviours which triggered others residents and caused her to retaliate.

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Requirements to address Responsive Behaviours - LTCHA s. 53

53. (1) Every licensee of a long-term care home shall ensure that the following are developed to meet the needs of residents with responsive behaviours:

1. Written approaches to care, including screening protocols, assessment, reassessment and identification of behavioural triggers that may result in responsive behaviours, whether cognitive, physical, emotional, social, environmental or other.2. Written strategies, including techniques and interventions, to prevent, minimize or respond to the responsive behaviours.3. Resident monitoring and internal reporting protocols.4. Protocols for the referral of residents to specialized resources where required. O. Reg. 79/10, s. 53 (1).

(2) The licensee shall ensure that, for all programs and services, the matters referred to in subsection (1) are,(a) integrated into the care that is provided to all residents;(b) based on the assessed needs of residents with responsive behaviours; and(c) co-ordinated and implemented on an interdisciplinary basis. O. Reg. 79/10, s. 53 (2).

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Requirements to address Responsive Behaviours - LTCHA Reg s. 53

(3) The licensee shall ensure that,(a) the matters referred to in subsection (1) are developed and implemented in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices;(b) at least annually, the matters referred to in subsection (1) are evaluated and updated in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices; and(c) a written record is kept relating to each evaluation under clause (b) that includes the date of the evaluation, the names of the persons who participated in the evaluation, a summary of the changes made and the date that those changes were implemented.

(4) The licensee shall ensure that, for each resident demonstrating responsive behaviours,

(a) the behavioural triggers for the resident are identified, where possible;(b) strategies are developed and implemented to respond to these behaviours, where

possible; and(c) actions are taken to respond to the needs of the resident, including assessments,

reassessments and interventions and that the resident’s responses to interventions are documented. O. Reg. 79/10, s. 53 (4).

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Behaviours and Altercations Altercations and other interactions between residents54. Every licensee of a long-term care home shall ensure that steps are taken to minimize the risk of altercations and potentially harmful interactions between and among residents, including,(a) identifying factors, based on an interdisciplinary assessment and on information provided to the licensee or staff or through observation, that could potentially trigger such altercations; and(b) identifying and implementing interventions.

Behaviours and altercations 55. Every licensee of a long-term care home shall ensure that,(a) procedures and interventions are developed and implemented to assist residents and staff who are at risk of harm or who are harmed as a result of a resident’s behaviours, including responsive behaviours, and to minimize the risk of altercations and potentially harmful interactions between and among residents; and(b) all direct care staff are advised at the beginning of every shift of each resident whose behaviours, including responsive behaviours, require heightened monitoring because those behaviours pose a potential risk to the resident or others. O. Reg. 79/10, s. 55.

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Is failure to follow care plan, neglect that is reportable to MOHLTC?

24. (1) A person who has reasonable grounds to suspect that any of the following has occurred or may occur shall immediately report the suspicion and the information upon which it is based to the Director:1. Improper or incompetent treatment or care of a resident that resulted in harm or a risk of harm to the resident.2. Abuse of a resident by anyone or neglect of a resident by the licensee or staff that resulted in harm or a risk of harm to the resident.3. Unlawful conduct that resulted in harm or a risk of harm to a resident.4. Misuse or misappropriation of a resident’s money.5. Misuse or misappropriation of funding provided to a licensee under this Act or the Local Health System Integration Act, 2006.

Duty on practitioners and others(4) Even if the information on which a report may be based is confidential or privileged, subsection (1) also applies to a person mentioned in paragraph 1, 2 or 3, and no action or other proceeding for making the report shall be commenced against a person who acts in accordance with subsection (1) unless that person acts maliciously or without reasonable grounds for the suspicion:1. A physician or any other person who is a member of a College as defined in subsection 1 (1) of the Regulated Health Professions Act, 1991.2. A person who is registered as a drugless practitioner under the Drugless Practitioners Act.3. A member of the Ontario College of Social Workers and Social Service Workers. 2007, c. 8, s. 24 (4).

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6. Police and LTC Homes and Retirement Homes • The police were informed after a resident was injured and she was

brought on a form to Victoria Hospital. During her stay in hospital, staff noted she was calm, and there were no incidents of physical behaviours or hallucinations.

• However upon return to the LTC environment, staff again noted similar behaviours to those displayed previously again due to her impairment, lack of insight, judgment, ability to communicate and paranoia (she threw hot soup on another resident; she was trying to kiss another resident who pulled away, and then she hit this resident; and again pulling another resident out of bed, this time her roommate who was seriously injuring her).

• Police were again called, and she was placed on a form 1 by the LTC physician, however the police charged her, and took her to the London Police Station. Ms. Castro was granted a 60 day psychiatric leave from the long-term care home

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Police Notification

LTCHA Regulation S.98Every licensee of a long-term care home shall ensure that the appropriate police force is immediately notified of any alleged, suspected or witnessed incident of abuse or neglect of a resident that the licensee suspects may constitute a criminal offence.

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Retirement Homes ActPolicy of zero tolerance of abuse and neglect

O. Reg 166/11 s. 15 Policy of zero tolerance of abuse and neglect15. …..(2) The procedures for investigating and responding to alleged, suspected or

witnessed abuse and neglect of residents described in clause 67 (5) (e) of the Act shall include details outlining who will undertake the investigation and who will be informed of the investigation.

(3) The policy to promote zero tolerance of abuse and neglect of residents described in subsection 67 (4) of the Act shall …(c) identify measures and strategies to prevent abuse and neglect;…

(f) provide that the licensee of the retirement home shall ensure that the appropriate police force is immediately notified of any alleged, suspected or witnessed incident of abuse or neglect of a resident that the licensee suspects may constitute a criminal offence

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7. Charges and Prosecution• Discretion to charge• Mens Rea (Guilty Mind) and Actus Rea (Guilty Act)

Key issues• Seriousness of the Office • Public safety, and • Whether the consequences of prosecution would be unduly harsh. • Province of Ontario, Ministry of Attorney General, “Mentally

Disordered/Developmentally Disabled Offenders”, Crown Policy Manual (March 21, 2005)

• Charge screening refers to the Crown counsel’s discretion in deciding to

continue to terminate a prosecution. The first step is always to determine if there is a reasonable prospect of conviction. This threshold test is objective and the standard is higher than a “prima facie” case. If there is a reasonable prospect of conviction, then Crown counsel must consider whether it is in the public interest to discontinue the prosecution. – Crown Policy Manual

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8. Conditions of Release • They were informed of her diagnosis, given a list of

medications and informed of our program’s involvement. Conditions were placed on Ms. Castro that prohibits her from returning to the LTC home. Ms. Castro was seen in court, and despite staff from our program advocating for an admission to the Psychiatric Intensive Care Unit at Victoria Hospital for further Geriatric Psychiatric assessment and treatment, she was charged with assault and remanded, being then transferred to Elgin Detention Centre in St. Thomas for assessment for 5 days to undergo undergo forensic assessment.

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Problems related to Release / Bail

• Lack of legal aid for representation by defense counsel because probably first offence/ not likelihood of incarceration

• ALSO NO CERTIFICATES for Legal Defense Counsel because Seniors Guaranteed Income EXCEEDS max for eligibility for legal aid certificate

• Lack of knowledge of LTC health system by Duty Counsel about risk of losing bed in LTC home if absent without proper leave or if absent for more time than permitted ; about absence of alternatives to LTC home ( so need to get assistance for person IN LTC HOME not remove them form that place; that LT+C homes may ( probably) will refuse admission in person loses bed and has to reapply elsewhere

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9. Chicken or Egg – Form 1 or Criminal Charge?

• It was explained that because she was charged and “remanded” instead of “released” the charge supersedes the Form 1 and therefore she cannot be sent to Victoria Hospital and admitted to the PICU because it is not a detention centre. The rationale for this action was that the court could not ensure that she would be held at the hospital and not returned to LTC after the form expired in 72 hours.

• My opinion its the opposite … Hmmmm • Forensic assessment – NCR

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10. Lost in the System? • Upon being transferred to the Elgin Detention Centre, they

stated that the Form 1 always supersedes criminal charges and Ms. Castro was sent back to the Victoria Hospital Emergency Department because it is apparent that she has dementia and needs treatment under the Form 1. Ms. Castro required police escort and 24 hour police supervision while in hospital. She remained an inpatient for five weeks. Subsequently she was discharged from the adult mental health inpatient unit at LHSC to the Elgin Middlesex Detention Centre (EMDC). From there she would be transferred to the secure forensic mental Health unit in Milton. Behaviour recommendations were supplied upon discharge from hospital, and Ms. Castro was discharged also from our program.

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Case 2 - Mary • We were referred Mary, who was expressing responsive behaviours related to a recent move to a

secure unit in long-term care. The behaviours of concern included frequently wishing to exit the floor and frequent verbalizations towards staff.

• During our initial visit, we discovered that Mary had previously been living in her long-time family home. Due to complex physical health issues, she was brought to hospital for treatment. While in hospital, Mary was diagnosed with "probable dementia", and was also deemed incapable to make decisions regarding housing through a CCAC Capacity Assessment. The closest family member was contacted, who chose to this lady to a long-term care home in a secure unit.

• This move was very distressing to this client, who did not agree with the location of the home. This lady had resided in a particular area of the city for a long time, and found this area more familiar and accessible to amenities. This move to a secure unit was also quite distressing. Shortly after, Mary was moved to a non-secure area within the same home.

•Several weeks later, this client signed out of the home to visit with a friend, and to return home to collect some belongings. When at home, this client picked up her personal vehicle to bring to the long-term care facility. Unfortunately, Mary had forgotten that her license had been revoked in hospital, that there was no car insurance on the vehicle, and the vehicle was not plated. Upon return, the LTCH contacted the police, who recommended that this client be placed back into the secure unit.

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Mary • When meeting with her, Mary expressed that this decision was quite unjust. She had not been

involved in this decision. When moved back to the secure unit, she did not relate well to her peers, who were far more advanced in their dementia when compared to her. She did not relate well to the activities that were run on this unit. She became quite fixated on leaving the unit and subsequently the building to reside alone. She memorized the exit code several times, which resulted in the need to change the code often. She began to contact family and acquaintances frequently, which became very disruptive in their lives. As a result, family chose to disconnect her phone.

• This became a trigger for this client, who believed this to be a problem with Rogers Communications and was extremely upset that no one was able to assist her in resolving the issue when she called.

• Our primary concerns were:

1) when choosing a home, not taking into consider the clients expressed wishes2) the police recommendation: this lady exited the home, but returned on time for dinner. She did not exit unsafely. The risk lies in unsafe driving. It seems other recommendations-such as discussing with this lady selling her car (she is still financially capable) could have been explored first3) removing her phone: she is still capable, so this should not have been done on her behalf. Additionally, we believed that removing the phone was in the best interest of family, rather than the client.

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1. Secure Units in LTC – Legislation has never been Proclaimed in effect

• We were referred Mary, who was expressing responsive behaviours related to a recent move to a secure unit in long-term care. The behaviours of concern included frequently wishing to exit the floor and frequent verbalizations towards staff.

• Question – Is a Locked unit even legal now ? The provisions about locked units NEED to be proclaimed to protect residents and staff and licensees and health practitioners

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2a. Incapacity for What? • Due to complex physical health issues, she was brought to hospital for

treatment. While in hospital, Mary was diagnosed with "probable dementia", and was also deemed incapable to make decisions regarding housing through a CCAC Capacity Assessment. The closest family member was contacted, who chose to this lady to a long-term care home in a secure unit.

CCACs evaluators access capacity to make decision about ADMISSION to LTC Not capacity for housing ( two different things – one under HCCA and other under SDA – so possible DIFFERENT SDMs. )

Was Mary given RIGHTS ADVICE INFO about right to review finding of incapacity at CCB and assisted to contact CCB? Get legal counsel? Was she actually incapable for admission decisions based on the other facts about her abilities to understand and appreciate ?

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2b. Who is the SDM? • The closest family member was contacted, who chose to this

lady to a long-term care home in a secure unit.

• Closest family members are not necessarily the SDMs • Must be highest in hierarchy in HCCA • How SDMs to make decision for Incapable person• Wishes • Best interests

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3. Choice of LTC Home • This move was very distressing to this client, who did not agree with

the location of the home. This lady had resided in a particular area of the city for a long time, and found this area more familiar and accessible to amenities. This move to a secure unit was also quite distressing. Shortly after, Mary was moved to a non-secure area within the same home.

• Why a secure unit? What was the need for this? Is tis SDM her SDM for treatment too or is she capable of making treatment decisions as that is relevant to being in a locked unit?

• Why this home? If needed crisis admit , did SDM place homes that would have been woman’s preference as first priority to remain on waiting list for a transfer? Mary could communicate preferences for other locations – was she really incapable for this purpose?

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4. Police Involvement • Several weeks later, this client signed out of the home to visit with a

friend, and to return home to collect some belongings. • When at home, this client picked up her personal vehicle to bring to

the long-term care facility. Unfortunately, Mary had forgotten that her license had been revoked in hospital, that there was no car insurance on the vehicle, and the vehicle was not plated. Upon return, the LTCH contacted the police, who recommended that this client be placed back into the secure unit.

• Why did LTC home call Police? Mary wasn’t missing. Was it because she drove without a licence?

• Why police “recommending” Mary be placed in secure unit? Police have no authority about secure unit and placement in secure unit for her care needs.

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5. Authority (or NOT) to detain on a locked unit

• When meeting with her, Mary expressed that this decision was quite unjust. She had not been involved in this decision. When moved back to the secure unit, she did not relate well to her peers, who were far more advanced in their dementia when compared to her. She did not relate well to the activities that were run on this unit.

• She became quite fixated on leaving the unit and subsequently the building to reside alone. She memorized the exit code several times, which resulted in the need to change the code often. She began to contact family and acquaintances frequently, which became very disruptive in their lives. As a result, family chose to disconnect her phone.

• This became a trigger for this client, who believed this to be a problem with Rogers Communications and was extremely upset that no one was able to assist her in resolving the issue when she called.

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Authority (or NOT) to detain on a locked unit

• Does the LTC home have authority to detain Mary on a locked unit? LTC homes do not have same detention authority as psychiatric facilities

• LTC home’s “Duty of Care” and what that means• Were the care services and activities etc on the locked unit

appropriate to Mary’s needs? If not , what does that mean for Mary and for the LTC home?

• The telephone – who was paying for that? Was Mary capable of managing her own money ? What authority did the family have to remove her phone? Did anyone tell Mary that the family removed the phone and it wasn’t a Rogers problem? Did Mary have the ability to understand that if she was told?

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