NEW: Ministry inspectors cite long-term care home over resident's death following scathing military report

After a report from the Canadian Armed Forces warned that residents at Hawthorne Place long-term care home died from neglect and dehydration during an outbreak, five inspectors spent over two months in the home investigating the claim.

They have made a single finding.

(A Toronto paramedic rolls a stretcher into the main entrance at Hawthorne Place Long Term Care Centre, May 20, 2020. Andrew Francis Wallace/Toronto Star)

In dry, bureaucratic language, a report posted to a government website details how a resident died after the home failed to ensure its staff members collaborated with each other. The resident was "eating and drinking poorly, and their health status worsened," the home failed to notify its staff physician, and the resident died, it found.

That was despite the fact that the resident had recently been discharged from a hospital and the home was directed to readmit the resident if their health status worsened.

"The resident's condition was at risk of declining when the staff did not collaborate in their assessment of the resident related to their symptoms," the report found.

The inspection report states it was in response to the military's allegations "that residents were not fed and not offered fluids during the home's COVID-19 outbreak during a specified period of time."

In fact, notes on a May 18, 2020 CAF meeting about the Hawthorne Place long-term care facility said: "The ACCT [augmented civilian care team] described that when they first arrived at the [long-term care facility] there was 'feces and vomit on floors and on the walls.' One ACCT member discovered that two of the residents had dried feces under their fingernails for a prolonged period of time. The ACCT Team reported that there had been resident deaths due to dehydration and malnourishment."

The owners of the home have adamantly denied any residents died from neglect.

The report notes that inspectors "reviewed the health records of residents who expired during the identified time." They also spoke with the home's management and staff, including its physicians, as well as a vice president of North York General Hospital.

As result, they made one finding. It's a "written notification," the lowest tier of consequences available to the home under provincial legislation, which does not require any mandatory followup or verification from the home to demonstrate compliance.

While the report details a single death, it leaves many questions unanswered about the documented concerns of the Canadian Armed Forces.

Families who lost loved ones, advocates and legal experts have been calling on the province to toughen up its enforcement of long-term care homes. As part of that, one legal advocate for the elderly has been calling on the province to employ investigators with greater legal powers.

Today, the ministry sends inspectors to homes but they don't have the power to actually investigate allegations of wrongdoing or substandard care, lawyer Jane Meadus recently told QP Briefing. The inspectors can't legally weigh evidence, make findings or lay charges under the Act. What that means, in practice, is if a home denies an allegation made by a resident or their loved ones, the denial is taken at face value and no finding is made, according to Meadus.

That's why Meadus is also calling for the legislation to include adding investigators to the ministry's roster and giving them the power to investigate, rather than just inspect, and to lay charges where appropriate without having to turn to local police. That, according to Meadus, is almost never done today even when an investigator finds a violation of the law, such as a failure to report abuse.

The ministry also initiated an inspection after another Canadian Armed Forces report on Downsview Long-Term Care Centre. The results of that inspection have not yet been posted to the ministry website.

QP Briefing has reached out to the Ministry of Long-Term Care and the ownership of Hawthorne Place for comment.

Editor's note: After the initial publication of this article, the inspection report was removed from the ministry's public-facing website. You can read a copy of it below.