Defining Responsive Behaviours

An early focus of the sparse body of research investigating responsive behaviours was incidence and prevalence measurement (Castle, 2012; Ferrah et al., 2015; McDonald et al., 2015; Rosen et al., 2008). But determination of incidence and prevalence was complicated by challenges associated with defining resident-to-resident aggression (Ferrah et al., 2015; McDonald et al., 2015; Ramirez et al., 2013). Responsive behaviours are associated with behavioural and psychological symptoms of dementia, the most common of which is aggression (Ontario Long Term Care Association, 2016). These symptoms may be manifest as “being verbally or physically abusive, socially disruptive, or resisting care and assistance….irritable outbursts, pushing or hitting” (Ontario Long Term Care Association, 2016, p. 7). A scoping review of the literature discerned multiple terms used to explain what is meant by resident-to-resident aggression including: (1) “abuse”; (2) “aggression”; (3) “elder mistreatment”; (4) “relational aggression”; (5) “violence”; (6) “violent incidents”; and (7) “non-staff abuse” (McDonald et al., 2015, p. 2).

Many of those terms evoke notions of intentional abuse/violent behaviour but “in most cases this is not true aggression, but a response to something in the person’s environment” (Ontario Long Term Care Association, 2016, p. 7). The term ‘responsive behaviours,’ incorporated in the Ontario LTC home legislation, refers to the diverse challenging behaviours that people with dementia may experience as a result of unmet needs or situations that may be “frustrating, frightening, or confusing to a person” (Alzheimer Society of Ontario, Alzheimer Knowledge Exchange, and Behavioural Supports Ontario, 2013; Government of Ontario, 2011, p. 2–33; Ontario eLaws, 2021a, b).

Rationale for Focus on Responsive Behaviours

A seminal report on the lack of and need for addressing safety in Canadian long-term care settings first identified “examining aggressive resident behaviour and related adverse events” as a gap in research and a national LTC safety priority (Rust et al., 2008, p. 5; Wagner & Rust, 2008). Since then, scholars publishing on the topic agree that such aggression remains widespread, underreported, and understudied (Botngård et al., 2020; Caspi, 2018; Castle, 2012; Ferrah et al., 2015; McDonald et al., 2015; Rosen et al., 2008).

The profile of Ontario LTC home residents further informed rationale for the study focus on responsivebehaviours. A total of 109,410 older adults, almost 55% of whom are 85 years of age and older, and approximately 67% of whom are women, reside in LTC homes in Ontario (Canadian Institute for Health Information, 2020). Since the 2010 adoption of the ‘Aging at Home’ policy, implementation of more stringent LTC home admission criteria has resulted in increasingly complex resident care needs (Ontario Long Term Care Association, 2019). Among residents assessed during 2019–2020: (a) 63.2% were diagnosed with dementia, (b) 33.6% were experiencing severe cognitive impairment, and (c) 43.9% exhibited some aggressive behavior (Canadian Institute for Health Information, 2020). These estimates are concerning because recent research supports that adverse events involving LTC home resident-to-resident aggression hold the potential for serious negative outcomes for the older adults involved, such as lacerations, bruises, fractures (Botngård et al., 2020; Castle, 2012; DeBois et al., 2020; Ferrah et al., 2015; McDonald et al., 2015; Rosen et al., 2008), and sometimes death (Caspi, 2018; DeBois et al., 2020; Murphy et al., 2017).

A report of an exploratory pilot study examined incidents associated with confrontations among LTC residents living with dementia that resulted in death (Caspi, 2018). From 1988 to 2017, the highest proportion (48%, n = 51/105) of examined incidents in six countries occurred in Canada (Caspi, 2018). Of those 51 deaths, the highest number (n = 37) happened in the province of Ontario (Caspi, 2018). The urgency of understanding more about how such events are managed informed the decision of members of Concerned Friends to select responsive behaviours as the prioritized care quality issue on which to conduct this analysis of public version Ontario LTC home inspection reports.

Ontario Long-term Care Quality Inspection Program

Since 2010, the Long-term Care Homes Act (2007) and Ontario Regulation 79/10 govern LTC in Ontario (Ontario eLaws, 2021a, b). Compliance with this legislation is tracked and enforced through the LTC Quality Inspection Program (Office of the Auditor General of Ontario, 2015a; Ontario Ministry of Health Ministry of Long-term Care, 2019; Ontario Ministry of Long-Term Care, 2020). A comparison study of LTC regulation among six countries, (Canada, the United States, Germany, Norway, Sweden, & England), determined that Ontario, Canada is one of two jurisdictions that applies the most deterrence-based, standardized inspection process (Choinière et al., 2016) to prevent adverse events that compromise the safety of LTC home residents and staff (Rust et al., 2008; Wagner & Rust, 2008).

Inspection Types

Several types of inspections are conducted all of which are unannounced. Inspection reports representing resident quality inspections, complaints, and critical incidents were reviewed in this study (Ontario Ministry of Health Ministry of Long-Term Care, 2019; Ontario Ministry of Long-Term Care, 2020). The annual frequency of resident quality inspections, also known as ‘comprehensive’ inspections, began in 2015 (Office of the Auditor General of Ontario, 2015a) but was temporarily discontinued in 2018. Complaints may be initiated by residents, their family members and/or members of the public (Office of the Auditor General of Ontario, 2015a; Ontario Ministry of Long-Term Care, 2020, 2021). Critical incident inspections arise from mandatory reports submitted to the ministry by LTC home administrators when critical incidents occur, such as unexpected/sudden death or abuse (Office of the Auditor General of Ontario, 2015a).

Inspection Process

Inspections follow a two stage sequence. The first stage entails interviews with a selected sample of residents, their family members and staff involved in their care, observations of care, and review of health records (Office of the Auditor General of Ontario, 2015a). After analyzing Stage One findings with the aid of standardized algorithms, Stage Two entails more in-depth analysis guided by 31 inspection protocols (Office of the Auditor General of Ontario, 2015a). The protocols are divided into three categories: (1) inspector initiated, (2) home-related, and (c) resident related (Office of the Auditor General of Ontario, 2015a). The five mandatory inspector initiated inspection protocols must be conducted in all resident quality inspections in either Stage One or Stage Two (Office of the Auditor General of Ontario, 2015a).

The responsive behaviours protocol falls within the resident related category (Office of the Auditor General of Ontario, 2015a). The inspection protocols each correspond to specific sections of the LTC home legislation (Ministry of Health and Long Term Care, 2010). Legislation sections concerning responsive behaviours address care requirements (Section 53), prevention of altercations and other interactions between residents (Section 54) and minimizing risk of harm through established procedures and interventions (Section 55) (Government of Ontario, 2011; Ministry of Health and Long Term Care, 2010; Ontario Ministry of Health Ministry of Long-Term Care, 2019, Ontario eLaws, 2021a, b).

Inspection Findings and Enforcement

Inspector decision making regarding inspection findings is guided by a computer assisted judgement matrix tool (Ministry of Health and Long Term Care, 2010; Ontario Ministry of Long-Term Care, 2020). On completion of each inspection, standardized reports are generated that summarize findings and specify required enforcement actions arising from the findings (Ministry of Health and Long Term Care, 2010; Office of the Auditor General of Ontario, 2015a; Ontario Ministry of Long-Term Care, 2021). These actions may include a (a) written notification; (b) voluntary plan of correction; (c) compliance order; (d) work and activity order; and/or director’s orders (Office of the Auditor General of Ontario, 2015a). Written notification and voluntary plans of correction are managed internally by the LTC home (Office of the Auditor General of Ontario, 2015a; Ontario Ministry of Long-Term Care, 2020). Compliance orders and director’s orders specify actions that LTC home administrators must take within specified time frames to address areas of non-compliance and these require inspector follow-up (Office of the Auditor General of Ontario, 2015a). Enforcement penalties include cease of admission orders, financial penalties; mandatory management orders; interim manager orders; and license revocation (Office of the Auditor General of Ontario, 2015a).

Report Dissemination

Two types of inspection documents are disseminated following each inspection. The licensee version, sent to the LTC home operator, contains all information related to the inspection (Ontario eLaws, 2021a, b). Personal and personal health information is redacted from the public version, to comply with privacy legislation and preserve resident anonymity (Ontario eLaws, 2021a, b). Ontario LTC legislation mandates public version inspection report posting on the Ontario Ministry of Health Ministry of Long Term Care website, distribution to each LTC home Resident and Family Councils, and posting in an accessible location in every LTC home (Ontario Ministry of Health Ministry of Long-Term Care, 2019; Ontario eLaws, 2021a, b). A copy of the public version of every inspection report is also sent to diverse stakeholders, including Concerned Friends.

Research Ethics Board Exemption

We received a Letter of Exemption from the University of Windsor Research Ethics Board in keeping with the Canadian Tri-Council Policy Statement on Ethical Conduct of Research with Humans - TCPS2 2014 Section 2.2 guidelines for research conducted solely with publicly available documents (Canadian Institutes of Health Research, National Sciences and Engineering Research Council of Canada, and Social Sciences and Humanities Research Council, 2014).