·1

·2

·3

·4

·5

·6

·7

·8

·9· · · · THE LONG-TERM CARE HOMES PUBLIC INQUIRY

10

11

12· · · · · · · · · · ·PUBLIC HEARINGS

13

14

15· · · · · · · · · · · · --------

16· · ·--- This is Day 30/Volume 30 of the Public

17· · Hearings in the above Inquiry proceedings taken

18· · at the Elgin County Courthouse, Court Room 201,

19· · 4 Wellington Street, St. Thomas, Ontario, on

20· · the 2nd day of August, 2018, commencing at

21· · 9:30 a.m.

22· · · · · · · · · · · · --------

23

24

25

26· · BEFORE:· The Honourable Justice Eileen E.

27· · · · · · ·Gillese, Commissioner

28

29

30· · REPORTED BY:· Deana Santedicola, CSR, CRR, RPR

31· · · · · · · ·&· Carissa Stabbler, RPR, CSR

32

Page 6844·1· · A P P E A R A N C E S:

·2

·3· · & Megan Stephens, Esq.,· · Commission Counsel

·4· · & Alexandra Campbell, Esq.,

·5· · & Lara Kinkartz, Esq.,

·6· · & Etienne Lacombe, Student-at-Law

·7· · & Sean Pierce, Student-at-Law

·8· · & Gregory Furmaniuk, Student-at-Law

·9

10· · David M. Golden, Esq.,· · ·Caressant Care

11· · · · · · · · · · · · · · · ·Nursing and

12· · · · · · · · · · · · · · · ·Retirement Homes

13· · · · · · · · · · · · · · · ·Limited, Caressant

14· · · · · · · · · · · · · · · ·Care - Woodstock

15

16· · Denise Cooney, Esq.,· · · ·College of Nurses

17

18· · Paul H. Scott, Esq.,· · · ·Jon Matheson,

19· · · · · · · · · · · · · · · ·Pat Houde,

20· · · · · · · · · · · · · · · ·Beverly Bertram

21

22· · Darrell Kloeze, Esq.,· · · Her Majesty the

23· · & Alexa Mingo, Esq.,· · · ·Queen in Right of

24· · & Kristin Smith, Esq.,· · · Ontario

25

26· · Nicole Butt, Esq.,· · · · ·Ontario Nurses

27· · & Kate Hughes, Esq.,· · · ·Association

28

29· · Jane Meadus, Esq.,· · · · ·Advocacy Centre

30· · & Suzan Fraser, Esq.,· · · for the Elderly

31

32

Page 6845·1

·2· · A P P E A R A N C E S (CONT'D):

·3

·4· · Matthew Czerwinski,· · · · Registered

·5· · Law Student,· · · · · · · ·Practical Nurses

·6· · · · · · · · · · · · · · · ·Association

·7

·8· · Lisa Corrente, Esq.,· · · ·Jarlette Health

·9· · · · · · · · · · · · · · · ·Services, Meadow

10· · · · · · · · · · · · · · · ·Park (London) Inc.

11· · · · · · · · · · · · · · · ·o/a Meadow Park

12· · · · · · · · · · · · · · · ·London Long-Term

13· · · · · · · · · · · · · · · ·Care

14

15· · Alex Van Kralingen, Esq.,· Arpad Jr. Horvath,

16· · & Katherine Chau, Esq.,· · Laura Jackson,

17· · · · · · · · · · · · · · · ·Don Martin,

18· · · · · · · · · · · · · · · ·Andrea Silcox,

19· · · · · · · · · · · · · · · ·Adam Silcox-Vanwyk,

20· · · · · · · · · · · · · · · ·Shannon Lee

21· · · · · · · · · · · · · · · ·Emmerton,

22· · · · · · · · · · · · · · · ·Jeffrey Millard,

23· · · · · · · · · · · · · · · ·Judy Millard,

24· · · · · · · · · · · · · · · ·Sandra Lee Millard,

25· · · · · · · · · · · · · · · ·Stanley Henry

26· · · · · · · · · · · · · · · ·Millard,

27· · · · · · · · · · · · · · · ·Susie Horvath

28

29

30

31

32

Page 6846·1· · · · · · · · INDEX OF PROCEEDINGS

·2

·3· · · · · · · · · · · · · · · · · · · · · · · PAGE

·4· · WITNESS:

·5· · RHONDA KUKOLY; Under Prior Oath

·6· · Examination In-Chief by Mr. Kloeze........6849

·7· · Cross-Examination by Mr. Van Kralingen....6850

·8· · Cross-Examination by Mr. Scott............6893

·9· · Cross-Examination by Ms. Corrente.........6907

10· · Cross-Examination by Mr. Golden...........6918

11· · Cross-Examination by Ms. Fraser...........6961

12· · Cross-Examination by Ms. Butt.............6998

13· · Re-Examination by Mr. Kloeze..............7002

14

15· · WITNESS:

16· · CAROL HEPTING; Under Prior Oath

17· · Further Cross-Examination by Ms. Fraser...7035

18· · Further Cross-Examination by Mr. Kloeze...7044

19· · Re-Examination by Mr. Golden (Cont'd).....7050

20

21· · WITNESS:

22· · NATALIE MORONEY;

23· · Examination In-Chief by Ms. Stephens......7054

24

25

26

27

28

29

30

31

32

Page 6847·1· · · · · · · · · · INDEX OF EXHIBITS

·2

·3· · NO.· DESCRIPTION· · · · · · · · · · · · ·PAGE

·4· · 137· Notes of Rhonda Kukoly dated

·5· · · · ·December 13, 2016.................. 6850

·6

·7· · 138· Document entitled "Medication

·8· · · · ·Management System Program

·9· · · · ·Evaluation," Document 43477........ 7013

10

11· · 139· Document entitled "Medication

12· · · · ·Management System Program

13· · · · ·Evaluation," Document 43480........ 7013

14

15· · 140· Document entitled "Medication

16· · · · ·Management System Program

17· · · · ·Evaluation," Document 43478........ 7013

18

19· · 141· Notes from the meeting with

20· · · · ·Sandra Fluttert dated November

21· · · · ·29, 2016........................... 7015

22

23· · 142· Affidavit of Natalie Moroney,

24· · · · ·sworn July 24, 2018................ 7056

25

26

27

28

29

30

31

32

Page 6848·1· · -- PROCEEDINGS COMMENCED AT 9:30 A.M. --

·2

·3· · · · · · · · · ·RHONDA KUKOLY:· UNDER PRIOR

·4· · · · · · · · · ·OATH.

·5· · · · · · · · · ·THE COMMISSIONER:· Good morning.

·6· · · · · · · · · ·MR. KLOEZE:· Good morning,

·7· · · · · · · · · ·Commissioner.· Good morning,

·8· · · · · · · · · ·Rhonda.

·9· · · · · · · · · · · Commissioner, I just have one

10· · · · · · · · · ·housekeeping matter to take care

11· · · · · · · · · ·of with the assistance of

12· · · · · · · · · ·Ms. Kukoly.

13· · · · · · · · · · · Earlier in the proceedings,

14· · · · · · · · · ·there were number of lettered

15· · · · · · · · · ·exhibits that were tendered --

16· · · · · · · · · ·or documents that were tendered

17· · · · · · · · · ·as lettered exhibits, and one of

18· · · · · · · · · ·them I propose to clear up today

19· · · · · · · · · ·with Ms. Kukoly.

20· · · · · · · · · · · These are notes or

21· · · · · · · · · ·transcription of an interview

22· · · · · · · · · ·that Ms. Kukoly had with

23· · · · · · · · · ·Karen Routledge at

24· · · · · · · · · ·Caressant Care.· It was tendered

25· · · · · · · · · ·on June 13, 2018, as exhibit

26· · · · · · · · · ·letter C.· I have additional

27· · · · · · · · · ·copies with me.

28· · · · · · · · · ·THE COMMISSIONER:· Thank you.

29· · · · · · · · · ·MR. KLOEZE:· If I can hand up

30· · · · · · · · · ·and have Ms. Kukoly identify

31· · · · · · · · · ·this document.

32· · · · · · · · · ·THE COMMISSIONER:· Thank you.

Page 6849·1· · · · · · · · · ·MR. KLOEZE:· Laura, it's

·2· · · · · · · · · ·actually Document Number 71619.

·3· · · · · · · · · ·EXAMINATION IN-CHIEF BY MR.

·4· · · · · · · · · ·KLOEZE:

·5· · · · · · · · · ·Q. Rhonda, are you familiar with

·6· · this document?

·7· · · · · · · · · ·A. Yes.

·8· · · · · · · · · ·Q. And what are they?

·9· · · · · · · · · ·A. This is my typed notes of the

10· · interview with the RN from Caressant Care

11· · Woodstock, Karen Routledge.

12· · · · · · · · · ·Q. And you prepared these notes?

13· · · · · · · · · ·A. I typed them, yes.

14· · · · · · · · · ·Q. Okay.· Thank you.

15· · · · · · · · · ·A. Although they're not

16· · verbatim.

17· · · · · · · · · ·Q. So you prepared these notes

18· · based on an audio recording of the interview?

19· · · · · · · · · ·A. Yes, and as well as at the

20· · time of the interview.

21· · · · · · · · · ·Q. Thank you.

22· · · · · · · · · ·MR. KLOEZE:· Madam Commissioner,

23· · · · · · · · · ·I propose to enter this as the

24· · · · · · · · · ·next exhibit in the proceedings.

25· · · · · · · · · ·THE COMMISSIONER:· All right.

26· · · · · · · · · ·Exhibit 137, I believe; is that

27· · · · · · · · · ·right, Madam Clerk?

28· · · · · · · · · ·THE REGISTRAR:· That's correct.

29· · · · · · · · · ·THE COMMISSIONER:· All right.

30· · · · · · · · · ·So what had been earlier entered

31· · · · · · · · · ·in these proceedings as lettered

32· · · · · · · · · ·Exhibit C is now entered as

Page 6850·1· · · · · · · · · ·Exhibit 137, the notes of this

·2· · · · · · · · · ·current witness.· And they're

·3· · · · · · · · · ·dated, aren't they?

·4· · · · · · · · · ·MR. KLOEZE:· December 13, 2016.

·5· · · · · · · · · ·THE COMMISSIONER:· Yes.

·6· · · · · · · · · ·Thank you.· December 13th, 2016.

·7· · · · · · · · · ·Exhibit 137.· Thank you.

·8· · · · · · · · · ·EXHIBIT NO. 137:· Notes of

·9· · · · · · · · · ·Rhonda Kukoly dated December 13,

10· · · · · · · · · ·2016.

11· · · · · · · · · ·MR. KLOEZE:· Okay.· Thank you,

12· · · · · · · · · ·Commissioner.

13· · · · · · · · · ·MR. VAN KRALINGEN:· Good

14· · · · · · · · · ·morning, Commissioner.

15· · · · · · · · · ·THE COMMISSIONER:· Good morning,

16· · · · · · · · · ·Mr. Van Kralingen.

17· · · · · · · · · ·CROSS-EXAMINATION BY MR. VAN

18· · · · · · · · · ·KRALINGEN:

19· · · · · · · · · ·Q. Good morning, Rhonda.

20· · · · · · · · · ·A. Good morning.

21· · · · · · · · · ·Q. My name is Alex

22· · Van Kralingen.· I'm one of the lawyers

23· · presenting one of the victim groups here.

24· · · · · · · · · ·A. Yes.

25· · · · · · · · · ·Q. I placed just at your chair

26· · there a yellow compendium of documents.

27· · · · · · · · · ·MR. VAN KRALINGEN:· Madam

28· · · · · · · · · ·Commissioner, I believe you have

29· · · · · · · · · ·the same compendium.

30· · · · · · · · · ·THE COMMISSIONER:· Yes.

31· · · · · · · · · ·Thank you very much.

32· · · · · · · · · ·BY MR. VAN KRALINGEN:

Page 6851·1· · · · · · · · · ·Q. I'm going to also ask you,

·2· · Rhonda, to keep your Affidavit close because

·3· · I'm going to bounce between both documents.

·4· · · · · · · · · ·Before I start with my

·5· · questions, though, I actually wanted to

·6· · thank you on behalf of my clients for some of

·7· · your self-reflection yesterday, particularly in

·8· · connection to the 2014 review you did of

·9· · Meadow Park and the hydromorphone that went

10· · missing there.· I know that they would have

11· · appreciated it.

12· · · · · · · · · ·That said, I'm going to start my

13· · conversation today about that same inspection

14· · just to better understand your answers just a

15· · little bit.

16· · · · · · · · · ·There was an open question from

17· · our earlier conversation with Ms. Nicholas when

18· · she was on the stand as to whether she

19· · participated in this inspection.

20· · · · · · · · · ·From my review of your notes, it

21· · appears that you did speak with her.· Now, I

22· · know that you don't have an independent

23· · recollection; is that fair to say?

24· · · · · · · · · ·A. I have a general one. I

25· · remember being in the home doing that

26· · inspection to a degree, and I remember sitting

27· · at the table.· I can't picture in my mind

28· · everyone that was at that table, but I know

29· · that if I documented those people were at the

30· · table, then that's who was at that table.

31· · · · · · · · · ·Q. Okay.· Sort of going to the

32· · first part of your answer, if we start at

Page 6852·1· · paragraph 76 and 77 of your Affidavit, I want

·2· · to be clear.· And we're going to pull it up on

·3· · the screen.

·4· · · · · · · · · ·If a member of the public were

·5· · reading your Affidavit -- go down to 77

·6· · actually, sorry.· Perfect.

·7· · · · · · · · · ·If a member of the public read

·8· · your Affidavit, they might have the impression

·9· · that you have an independent recollection.· And

10· · so am I to understand that starting at

11· · paragraph 77 and moving down in your Affidavit,

12· · when you're referencing the 2014 inspection of

13· · Meadow Park, you essentially use your notes as

14· · of that time to refresh your recollection, and

15· · that's what we're basing the Affidavit on?

16· · · · · · · · · ·A. Yes.

17· · · · · · · · · ·Q. Okay.· Can we go to the

18· · inspection report at Tab 9 of your documents,

19· · and it's Document 39398.

20· · · · · · · · · ·A. I have that as the medication

21· · IP, not the inspection report.

22· · · · · · · · · ·Q. I put it in my notes as the

23· · inspection report, but you're absolutely right.

24· · That's what it is.

25· · · · · · · · · ·A. Okay.· I just want to make

26· · sure that we're looking at the same thing.

27· · · · · · · · · ·Q. We are looking at the same

28· · thing.· Thank you for clarifying.

29· · · · · · · · · ·Can you pull back just a little

30· · bit in terms of the zoom?· Perfect.· And can

31· · you go to page 5, please.· Actually, page 4.

32· · Sorry.

Page 6853·1· · · · · · · · · ·On the bottom of the page,

·2· · there's a reference to an 11:14 interview with

·3· · Melanie ADOC.· I assume that means the

·4· · assistant deputy of care.· Would you agree with

·5· · that?

·6· · · · · · · · · ·A. Well, then I'm not on the

·7· · same page as you.

·8· · · · · · · · · ·Q. Page 4.

·9· · · · · · · · · ·A. Oh, I had 2.· Sorry.· Yeah.

10· · · · · · · · · ·Q. Okay.· So at the bottom of

11· · the page, there's a reference to who you meet

12· · with.· When I see Melanie, an ADOC, I assume

13· · that means Assistant Director of Care; is that

14· · fair to say?

15· · · · · · · · · ·A. Yes.

16· · · · · · · · · ·Q. And the next one is Heather

17· · Nicholls, Director of Care.· Do I have that

18· · right?

19· · · · · · · · · ·A. Yes.

20· · · · · · · · · ·Q. Based on a review of your

21· · notes, do you believe Ms. Nicholls was part of

22· · this meeting with you?

23· · · · · · · · · ·A. Based on my notes, yes.

24· · · · · · · · · ·Q. Okay.· Laura, if you could

25· · pull up the July 30th transcript at page 6289.

26· · · · · · · · · ·Earlier in these proceedings --

27· · and I think you were present -- Ms. Simpson

28· · provided evidence about the circumstances under

29· · which there would be mandatory reporting of an

30· · inspector to the College, and she indicated

31· · there were no circumstances of mandatory

32· · reporting.

Page 6854·1· · · · · · · · · ·A. I'm sorry.· That -- can you

·2· · say that again?

·3· · · · · · · · · ·Q. Sure.· Ms. Simpson had a

·4· · conversation with Mr. Kloeze, and in that

·5· · conversation, she talked about how there was

·6· · not mandatory reporting from inspectors to the

·7· · College of Nurses if there was a concern about

·8· · a competence or capacity issue.

·9· · · · · · · · · ·A. Okay.

10· · · · · · · · · ·Q. During the course of that

11· · answer, though, she provided this quote.· She

12· · said:· [AS READ]

13· · · · · · · · · ·"Now, saying that, I know that

14· · · · · · · · · ·our nurse inspectors will raise

15· · · · · · · · · ·these issues with employers to

16· · · · · · · · · ·ensure they have reported and

17· · · · · · · · · ·they will ask the question

18· · · · · · · · · ·because they are nurses, and so

19· · · · · · · · · ·they do take that seriously."

20· · She also indicates that she knows that they've

21· · had nurse inspectors report in the past.· And

22· · so my question was -- is, pardon me, as of

23· · 2014, was that your understanding of how an

24· · inspector would or should proceed where there

25· · is an open question about a nurse's competence,

26· · conduct, or capacity?

27· · · · · · · · · ·A. Yes.· It's my understanding

28· · that I did not have an obligation to report;

29· · however, it was my usual practice to ask the

30· · home if they had notified the College under

31· · their obligation as the employer.

32· · · · · · · · · ·That's my understanding.· And I

Page 6855·1· · didn't -- and if I did and I don't remember, I

·2· · didn't document it, so I have to say I didn't.

·3· · · · · · · · · ·Q. No, I understand that, but

·4· · I'm just talking about what your practice was

·5· · at the time.· So your practice would be to

·6· · raise the issue with the employer and rely on

·7· · the employer to meet their obligations, if any,

·8· · to report to the College; is that fair to say?

·9· · · · · · · · · ·A. Yes.

10· · · · · · · · · ·Q. So there would be no moment

11· · where you directly would report to the College?

12· · · · · · · · · ·A. I would say likely if I had a

13· · concern and the home hadn't -- -- and I felt

14· · the home definitely should have reported, and I

15· · thought of it at that time during that

16· · inspection, then I would likely speak to my

17· · manager about that.

18· · · · · · · · · ·I don't think it would

19· · necessary -- it's not that I wouldn't call, but

20· · that would be something that my manager would

21· · need to know about, that I'm going to call an

22· · outside agency and notify them about a nurse

23· · who's working and around my inspection.· And

24· · she would need to know that as the manager of

25· · the SAO, that this information is passing to an

26· · outside agency.

27· · · · · · · · · ·So I would talk to them, and it

28· · doesn't mean that I wouldn't call or they --

29· · but they might call, but I would discuss that

30· · with them, and we would make that decision.

31· · · · · · · · · ·Q. So two questions flowing from

32· · that:· First, would that conversation with your

Page 6856·1· · manager happen regardless of whether you had

·2· · confidence that the employer had reported to

·3· · the College of Nurses?

·4· · · · · · · · · ·A. If I was confident that the

·5· · home had reported, then I would have accepted

·6· · that.· It's no different than any other

·7· · information that I gather from a home.

·8· · · · · · · · · ·I have to trust that when the

·9· · home tells me something, they're telling me the

10· · truth unless I have some other evidence that

11· · tells me otherwise.

12· · · · · · · · · ·And then in that case, I'd ask

13· · more questions.· But I have no means of being

14· · able to determine if they're telling me the

15· · truth, and I'm going to trust them.

16· · · · · · · · · ·Q. Okay.

17· · · · · · · · · ·A. And that's their obligation.

18· · So oftentimes, if you were to ask them that and

19· · they said no, that would probably be a trigger

20· · that maybe we better do this or --

21· · · · · · · · · ·Q. So the manner in which you

22· · get confidence, what you're suggesting to me,

23· · is just through a verbal conversation you have

24· · with the Director of Care or the administrator

25· · at any given home you inspect at?

26· · · · · · · · · ·A. Yes.· However, there are

27· · times when they are able to provide me with

28· · documents that they've -- if they've done a

29· · written report to the College, they've received

30· · something back, they might provide that to me

31· · as further evidence.

32· · · · · · · · · ·Q. Let's talk about the second

Page 6857·1· · part of your answer, the fact that you would

·2· · engage with your manager.

·3· · · · · · · · · ·Is there an internal process or

·4· · reason why you would have to engage with your

·5· · manager before you would be able to contact the

·6· · College?

·7· · · · · · · · · ·A. No, I don't -- I don't think

·8· · there's a formal process, but I think that's a

·9· · standard of practice and a manager's right to

10· · know what's happening in their office and

11· · what's -- because they're going to have -- they

12· · might potentially have to be the liaison if

13· · there's communication with the College further

14· · to that, so they need to be involved and have

15· · that information.

16· · · · · · · · · ·Because it's likely that the

17· · College and that communication is going to be

18· · higher up than me, and they need to be aware.

19· · I need to give them the respect of knowing

20· · what's going on.

21· · · · · · · · · ·Q. I'm not suggesting they

22· · shouldn't know what's going on.· I want to be

23· · clear.· I'm trying to understand whether you

24· · think you need permission from a manager to

25· · contact the College or whether you would just

26· · inform your manager that you had contacted the

27· · College.

28· · · · · · · · · ·A. I don't think I need

29· · permission.· I think it's a respect.

30· · · · · · · · · ·Q. I actually agree with that.

31· · · · · · · · · ·How many times in the course of

32· · your career have you consulted with a manager

Page 6858·1· · about contacting the College of Nurses in

·2· · connection with a nurse?

·3· · · · · · · · · ·A. I haven't contacted the

·4· · College, so...

·5· · · · · · · · · ·Q. Your discussion of a

·6· · collaborative conversation with the manager

·7· · before the College would be contacted, do you

·8· · have a sense if that was the practice of other

·9· · inspectors you worked with in 2014?

10· · · · · · · · · ·A. I'm aware through Karen's

11· · statement that other inspectors have done that,

12· · and that's my only knowledge.

13· · · · · · · · · ·Q. To the best of your knowledge

14· · as an inspector since Ms. Wettlaufer's crimes

15· · have come to light, has the Ministry

16· · communicated anything to inspectors reminding

17· · them about the circumstances under which those

18· · inspectors may want to voluntarily inform the

19· · College about concerns relating to a nurse's

20· · conduct, competence, or capacity?

21· · · · · · · · · ·A. Not to my knowledge.

22· · · · · · · · · ·Q. Is it fair to say that you

23· · believed that -- that you believed Meadow Park

24· · strongly suspected Ms. Wettlaufer was

25· · responsible for the removal of hydromorphone?

26· · · · · · · · · ·A. They suspected her.

27· · · · · · · · · ·Q. And it's fair to say that

28· · Meadow Park had contacted the College of

29· · Nurses?

30· · · · · · · · · ·A. No.

31· · · · · · · · · ·Q. You didn't assume that they

32· · had contacted the College of Nurses?

Page 6859·1· · · · · · · · · ·A. No, I said I didn't think of

·2· · it at that time, so I didn't -- I didn't think

·3· · to ask them.

·4· · · · · · · · · ·Q. That's fair.

·5· · · · · · · · · ·A. Which is my...

·6· · · · · · · · · ·Q. In 2014, was the identity of

·7· · the nurse who took the hydromorphone pills

·8· · disclosed to you?· Was Ms. Wettlaufer's name

·9· · told to you in 2014?

10· · · · · · · · · ·A. Yes, because it's in the

11· · medication IP.

12· · · · · · · · · ·Q. Her actual name is in this?

13· · · · · · · · · ·A. I believe so.· So if you look

14· · on that page 4 --

15· · · · · · · · · ·Q. Yes.

16· · · · · · · · · ·A. -- there's a note on

17· · November 4th at 13:00, a staff interview with

18· · Melanie --

19· · · · · · · · · ·Q. It is there.· I see it, yes.

20· · Okay.

21· · · · · · · · · ·In your role as an inspector

22· · when you learn about a potential capacity issue

23· · relating to a specific nurse, in particular,

24· · that that capacity issue was connected to

25· · alcohol or drug use, to your mind, should that

26· · trigger a review of the quality of care that

27· · that nurse was providing to residents?

28· · · · · · · · · ·A. It's going to depend on the

29· · inspection that I'm doing.

30· · · · · · · · · ·Q. In what way?

31· · · · · · · · · ·A. So we have -- one way or the

32· · other, we have a reason to do an inspection, we

Page 6860·1· · have a trigger.· The trigger could be a

·2· · critical incident that the home reported, a

·3· · complaint that came in, or it could be a

·4· · trigger from stage 1 to stage 2 in an RQI.

·5· · · · · · · · · ·So I need to stay focused on the

·6· · trigger and the reason for the inspection, but

·7· · if the inspection takes me there to look at an

·8· · employee file to determine if there had

·9· · previously been performance issues with a staff

10· · member that could potentially give the home

11· · reason to suspect that something could happen

12· · again, that they need to take action on to

13· · protect the residents or to ensure the safety

14· · of the residents, then I would look at that.

15· · · · · · · · · ·But that's a very broad

16· · statement.· It's going -- it's always going to

17· · depend on the circumstances of that inspection

18· · and everything else involved in that.

19· · · · · · · · · ·Q. That's fair.

20· · · · · · · · · ·A. So it's very generalized, but

21· · we will look at employee files.

22· · · · · · · · · ·Q. Let's get specific on this

23· · file.· Ms. Wettlaufer had a termination letter.

24· · In that termination letter -- sorry, a

25· · resignation letter.· I apologize.

26· · · · · · · · · ·In that resignation letter, she

27· · indicated that she had a condition which would

28· · limit her ability to work as a nurse down the

29· · road.

30· · · · · · · · · ·A. Yes.

31· · · · · · · · · ·Q. Did you see that resignation

32· · letter in the context of your inspection of

Page 6861·1· · this issue?

·2· · · · · · · · · ·A. I can't recall.· I believe I

·3· · said that I saw the doctor's note.

·4· · · · · · · · · ·Q. I'll put it this way:· Do you

·5· · feel that the content of that letter was

·6· · disclosed to you in your conversations with --

·7· · · · · · · · · ·A. Yes.

·8· · · · · · · · · ·Q. -- the management of the --

·9· · · · · · · · · ·A. Yes.

10· · · · · · · · · ·Q. Did the fact that

11· · Ms. Wettlaufer had indicated to Meadow Park

12· · that she was unable to work as a nurse going

13· · forward because of her medical condition

14· · trigger anything in your mind as to whether you

15· · should look at the quality of care she had been

16· · providing to residents before she resigned?

17· · · · · · · · · ·A. No.

18· · · · · · · · · ·Q. Can we go to paragraph 16,

19· · page 5 to 6 of your Affidavit?

20· · · · · · · · · ·A. Can you say those numbers

21· · again.

22· · · · · · · · · ·Q. Paragraph 16 and pages 5 to 6

23· · of your Affidavit.· It starts at the bottom of

24· · the page, Laura.

25· · · · · · · · · ·A. Yes.

26· · · · · · · · · ·Q. So there's a discussion here

27· · about management turnover and the effect of

28· · management turnover can have on the inspector's

29· · relationship when they show up.· And I'm

30· · wondering if we can talk about that a little

31· · bit.· Just go down a little bit more.· Perfect.

32· · · · · · · · · ·I think what you're talking

Page 6862·1· · about here is that seasoned inspectors, people

·2· · who have been in the community for a while or

·3· · know the home in question, will have a sense as

·4· · to whether there's management turnover at a

·5· · particular home.· Is it fair to say?

·6· · · · · · · · · ·A. To a degree.

·7· · · · · · · · · ·Q. Okay.· Is management --

·8· · · · · · · · · ·A. I can't say that I've been in

·9· · every home in our SAO in every one of the 150

10· · to be able to have a true sense of all of them,

11· · but --

12· · · · · · · · · ·Q. And I'm not suggesting that.

13· · I'm suggesting in the homes where you've had

14· · some sort of an inspection in the past and

15· · perhaps have gone a few times, you might have a

16· · sense of the management turnover?

17· · · · · · · · · ·A. Yes.

18· · · · · · · · · ·Q. Okay.· Do you think

19· · management turnover is significant in any way

20· · for the purposes of an investigation?· An

21· · inspection, pardon me.

22· · · · · · · · · ·A. It is significant because it

23· · impacts the ability for the managers to be able

24· · to give us information because if -- because if

25· · they weren't there when something happened or

26· · they weren't the one to have reported a

27· · critical incident and done the follow-up on

28· · that, then they're going to be relying on what

29· · the previous manager documented to be able to

30· · give me information.

31· · · · · · · · · ·Q. What you're suggesting is

32· · that they don't have institutional knowledge?

Page 6863·1· · · · · · · · · ·A. Yes.

·2· · · · · · · · · ·Q. Okay.· Is it possible that

·3· · management turnover might reflect other

·4· · instability in the home?

·5· · · · · · · · · ·A. I would almost say I would

·6· · look at it the other way around, that

·7· · management instability will have a rippling

·8· · effect on the frontline staff.

·9· · · · · · · · · ·Q. During the course of this

10· · inquiry, we've heard that around 2014, there

11· · was a lot of management change at Meadow Park.

12· · And I'm wondering, did the fact of the turnover

13· · in management in 2014 affect your analysis at

14· · all for the purposes of your inspection?

15· · · · · · · · · ·A. I can't recall.

16· · · · · · · · · ·Q. During the course of this

17· · inspection -- I'll start with this quote that I

18· · took from you yesterday.

19· · · · · · · · · ·You said that your function is

20· · for looking at the risk in that home, the home

21· · that you're attending; is that fair to say?

22· · · · · · · · · ·A. Yes.

23· · · · · · · · · ·Q. During the course of this

24· · inspection, did you turn your mind to where

25· · Ms. Wettlaufer might have subsequently worked?

26· · · · · · · · · ·A. No.

27· · · · · · · · · ·Q. As of the date of your

28· · report, it seems to indicate that you had no

29· · confidence that the police would lay charges in

30· · this instance; is that fair to say?

31· · · · · · · · · ·A. No.

32· · · · · · · · · ·Q. Did you attempt to contact

Page 6864·1· · the detective in charge of the investigation at

·2· · all?

·3· · · · · · · · · ·A. No.

·4· · · · · · · · · ·Q. You'll agree with me as of

·5· · the date of your report, there's nothing -- not

·6· · your report.· The inspection protocol.· There's

·7· · nothing precluding Ms. Wettlaufer from applying

·8· · for a new job?

·9· · · · · · · · · ·A. No.

10· · · · · · · · · ·Q. If you could look at Tab 10

11· · of the documents you have.· That's

12· · Document 39395.· This is the inspection report?

13· · · · · · · · · ·A. Yes.

14· · · · · · · · · ·Q. And so pursuant to this

15· · inspection report, you found no findings of

16· · noncompliance?

17· · · · · · · · · ·A. Yes.

18· · · · · · · · · ·Q. Okay.· Looking at the larger

19· · picture, you didn't find any noncompliance

20· · relying to the drug supply at Meadow Park, and

21· · yet you thought Meadow Park suspected

22· · Ms. Wettlaufer was responsible for stealing a

23· · large number of narcotics.

24· · · · · · · · · ·Upon reflection, do you believe

25· · there's a legislative gap of any sort with

26· · respect to the requirements under the Long-Term

27· · Care Homes Act which fail to prevent this theft

28· · of narcotics?

29· · · · · · · · · ·A. I don't know if I'm in a

30· · position to have an opinion on that.· I feel

31· · like I'd be stepping outside of my scope for

32· · that.

Page 6865·1· · · · · · · · · ·Q. Fair enough.· You believe it

·2· · would be helpful either as a legislated

·3· · obligation or as a best practice for inspectors

·4· · to identify to the director circumstances where

·5· · narcotics are stolen, but there's not a formal

·6· · finding of noncompliance under the act?

·7· · · · · · · · · ·A. I'm sorry.· Can you just say

·8· · that one more time?

·9· · · · · · · · · ·Q. Sure.· Do you believe that

10· · there should be either a -- given your

11· · experience here where we see drugs have been

12· · stolen but there's no formal finding of

13· · noncompliance, do you think there should be

14· · either a legislated obligation or perhaps a

15· · best practice within the Ministry to identify

16· · to the director circumstances where narcotics

17· · are stolen, but there's no finding of

18· · noncompliance?

19· · · · · · · · · ·A. I would say that any idea

20· · about best practice for inspections to try to

21· · improve everyone's knowledge of a situation and

22· · to be able to take actions from their vantage

23· · point of their position would be a good idea.

24· · It's something that could be looked at.

25· · · · · · · · · ·Q. So the answer to my question

26· · is "yes" then?

27· · · · · · · · · ·A. Outside of the legislation

28· · changes, I would say --

29· · · · · · · · · ·Q. You're not qualified to.

30· · Let's talk about best practice.

31· · · · · · · · · ·A. The best practice, that's

32· · something that definitely could be looked at.

Page 6866·1· · · · · · · · · ·Q. With respect to Meadow Park,

·2· · did you or anybody else from the Ministry

·3· · follow up regarding the status of the police

·4· · investigation or anything that Meadow Park

·5· · might have subsequently found out about what

·6· · happened to those drugs?

·7· · · · · · · · · ·A. No.

·8· · · · · · · · · ·Q. If we go the paragraph 78 of

·9· · your Affidavit, and that's at page 30.· In the

10· · middle of the paragraph, it says:· [AS READ]

11· · · · · · · · · ·"If management suspects a staff

12· · · · · · · · · ·member may have stolen

13· · · · · · · · · ·narcotics, I would want to know

14· · · · · · · · · ·what the home is doing about

15· · · · · · · · · ·that belief, e.g., whether the

16· · · · · · · · · ·home has contacted the police

17· · · · · · · · · ·and what systems the home has in

18· · · · · · · · · ·place to ensure the incident

19· · · · · · · · · ·cannot reoccur."

20· · It's that last part of the sentence I'm curious

21· · about.· With respect to Meadow Park, what

22· · comfort did you get in that regard, namely that

23· · the home had systems in place to ensure that

24· · the incident would not reoccur?

25· · · · · · · · · ·A. I would have to go back and

26· · read my medication IP and see the notes that I

27· · wrote.

28· · · · · · · · · ·Q. We'll treat it this way so I

29· · can be efficient this morning, and we don't

30· · have to read together.· If you had any thoughts

31· · in that regard, it would certainly be within

32· · that inspection protocol and nowhere else; is

Page 6867·1· · that fair to say?

·2· · · · · · · · · ·A. Yes.

·3· · · · · · · · · ·Q. Okay.· Let's look at the

·4· · final sentence.· It says:· [AS READ]

·5· · · · · · · · · ·"As an inspector, I need to know

·6· · · · · · · · · ·that there are processes in

·7· · · · · · · · · ·place to mitigate risks to

·8· · · · · · · · · ·residents so that I can confirm

·9· · · · · · · · · ·that the home has complied with

10· · · · · · · · · ·the legislation and the

11· · · · · · · · · ·regulation."

12· · Do you see that?

13· · · · · · · · · ·A. Yes.

14· · · · · · · · · ·Q. Is it fair to say that you

15· · were looking at your role through that lens of

16· · legislation and regulation?

17· · · · · · · · · ·A. Yes.

18· · · · · · · · · ·Q. But you'll agree with me that

19· · it's a different question as to the practical

20· · issues surrounding actual risk to residents?

21· · · · · · · · · ·Looking at something through

22· · legislation and regulation and whether you meet

23· · those regulations is separate from the

24· · practical question of whether residents are at

25· · risk, have been placed at risk, or could be

26· · placed at risk?

27· · · · · · · · · ·A. I would say that our program

28· · is resident-focused, and our inspections are

29· · resident-focused, and the legislation is

30· · resident-focused.

31· · · · · · · · · ·Q. Okay.· I'm going to shift

32· · gears and talk about the 2016 Meadow Park

Page 6868·1· · inspection.

·2· · · · · · · · · ·A. And I'm resident-focused.

·3· · Sorry, I had to say that.

·4· · · · · · · · · ·Q. Don't say sorry.

·5· · · · · · · · · ·Let's talk about the 2016 Meadow

·6· · Park inspection.· Just one quick question. I

·7· · anticipate Ms. Moroney, whose evidence will be

·8· · provided later in these proceedings, when she

·9· · talked about her 2016 inspection of Meadow Park

10· · will say that she was surprised to find a

11· · reference letter for Ms. Wettlaufer given by

12· · Caressant Care given what Ms. Moroney

13· · characterizes as Ms. Wettlaufer's performance

14· · issues, absentee issues, challenges with

15· · coworkers, and medication incidents.

16· · · · · · · · · ·And I'm wondering if you have

17· · any thoughts with respect to that -- do you

18· · have any comparable thoughts in connection with

19· · Meadow Park receiving a reference letter from

20· · Caressant Care?

21· · · · · · · · · ·A. Not to be cheeky, but it

22· · depends on your definition of "comparable."

23· · · · · · · · · ·Q. I'll take out comparable.· Do

24· · you have any thoughts about the fact that

25· · Meadow Park received a reference letter?

26· · · · · · · · · ·A. Yeah.· We saw that reference

27· · letter at some point in time.· I can't recall

28· · at this point whether it was initially before

29· · we went back into the home when we were doing

30· · our record review or whether it was once we

31· · were in the home.· I can't recall at this time.

32· · And it did -- it did raise a concern.· We did

Page 6869·1· · ask Wanda Sanginesi about that.

·2· · · · · · · · · ·Q. What did she say?

·3· · · · · · · · · ·A. You'd have to pull up my

·4· · interview.

·5· · · · · · · · · ·Q. Why did you ask her the

·6· · question?

·7· · · · · · · · · ·A. It was -- unfortunately,

·8· · that's a -- it's -- it's a difficult question

·9· · to answer because we don't -- I don't have

10· · legislation to speak -- that speaks to that to

11· · be able to put that in my inspection, but

12· · because it was a concern that I thought of at

13· · that time, I wanted to hear what the answer

14· · was.

15· · · · · · · · · ·Q. But why was it a concern?

16· · · · · · · · · ·A. Because she was terminated

17· · for a medication error that had a negative

18· · impact on a resident.

19· · · · · · · · · ·Q. And you thought it was

20· · inappropriate for the reference letter that was

21· · provided to have been provided given that

22· · medication error?

23· · · · · · · · · ·A. It wasn't that I thought it

24· · was inappropriate.· It wasn't reflective of

25· · what happened at the end of her employment with

26· · Caressant Care Woodstock.

27· · · · · · · · · ·Q. I'm going to move on to a new

28· · topic.· In the course of your Affidavit, you

29· · talk about the training that you received when

30· · you initially started working --

31· · · · · · · · · ·A. Mm-hm.

32· · · · · · · · · ·Q. -- with respect to conducting

Page 6870·1· · interviews and the fact that some more formal

·2· · training had subsequently been done with

·3· · inspectors with respect to how to conduct

·4· · interviews.· Do you remember that?

·5· · · · · · · · · ·A. Yes.

·6· · · · · · · · · ·Q. During that first point we

·7· · were talking about with respect to informal

·8· · training, do you remember receiving any

·9· · training whatsoever with respect to conducting

10· · interviews where somebody may be acting in a

11· · deceptive manner?

12· · · · · · · · · ·A. No.

13· · · · · · · · · ·Q. And in your more formal

14· · training sessions, the same question:· Did you

15· · receive any formal training with respect to how

16· · to conduct interviews with someone who may be

17· · being deceptive with you?

18· · · · · · · · · ·A. I can't say that I remember

19· · that.

20· · · · · · · · · ·Q. Okay.· Can you go to

21· · paragraph 27 of your Affidavit, which is at

22· · page 9 at the bottom.· That's great.· Thank

23· · you.

24· · · · · · · · · ·You talk about in 2016, CIATT

25· · became to advise the SAOs about trends seen in

26· · intakes for different homes.· And I just want

27· · to be clear.· Are those trends based on

28· · findings of noncompliance or all reports that

29· · are intook?

30· · · · · · · · · ·A. That's based on the critical

31· · incidents in the complaints that come in to

32· · CIATT.

Page 6871·1· · · · · · · · · ·Q. So there's no filter in terms

·2· · of compliance versus noncompliance with respect

·3· · to those trends?

·4· · · · · · · · · ·A. At the intake level, that

·5· · question would be better answered by Aislinn

·6· · because I don't do that job.

·7· · · · · · · · · ·Q. It's just in your Affidavit.

·8· · That's why I'm asking you about it.· And if you

·9· · can't answer --

10· · · · · · · · · ·A. To my knowledge, no, but I

11· · would suggest you talk to Aislinn about that to

12· · be sure.

13· · · · · · · · · ·Q. We may.

14· · · · · · · · · ·Go to paragraph 29 of your

15· · Affidavit, which is at page 10.· Your Affidavit

16· · discussed how there are timelines for level 2

17· · and level 3 inspections and how those timelines

18· · are not always met.· Do you remember that?

19· · · · · · · · · ·A. Yes.

20· · · · · · · · · ·Q. And yesterday, I took a quote

21· · down from you.· You said it's a manpower issue.

22· · So my question to you is do you feel that the

23· · London SAO office is properly resourced to meet

24· · the Ministry's obligations under the Long-Term

25· · Care Homes Act?

26· · · · · · · · · ·A. Currently, no --

27· · · · · · · · · ·Q. Can you go to paragraph 100?

28· · · · · · · · · ·A. -- to be honest.

29· · · · · · · · · ·Q. I didn't mean to interrupt

30· · you.· I think it may not have been captured.

31· · · · · · · · · ·A. Sorry.· I -- just to be

32· · really honest, I -- yeah.

Page 6872·1· · · · · · · · · ·Q. Just to be honest, you don't

·2· · feel that the London office has been properly

·3· · resourced to effect its obligations to inspect?

·4· · · · · · · · · ·A. At this current time.

·5· · · · · · · · · ·Q. Right.· Can you go to page 38

·6· · of your Affidavit and paragraph 100.· You

·7· · indicated that you had three days of interview

·8· · with Ms. Crombez in the context of the 2016

·9· · Meadow Park inspection and that she often

10· · responded "I don't remember" or "I don't

11· · recall."· I'd like to take you to Ms. Crombez's

12· · testimony on June 11th at page 937.

13· · · · · · · · · ·A. I remember that.

14· · · · · · · · · ·Q. In response to a question

15· · from me, Ms. Crombez characterized her

16· · conversations with the inspector saying, quote:

17· · [AS READ]

18· · · · · · · · · ·"And the inspectors, they were

19· · · · · · · · · ·brutal.· They were angry about

20· · · · · · · · · ·what had happened.· They would

21· · · · · · · · · ·ask me for documentation, and I

22· · · · · · · · · ·was busy trying to, you know,

23· · · · · · · · · ·fill beds, move residents to

24· · · · · · · · · ·create a space for them."

25· · I wanted to ask you if you could respond to

26· · Ms. Crombez's characterization of your

27· · interview with her.

28· · · · · · · · · ·A. I feel confident knowing that

29· · those interviews were audiotaped, that if you

30· · listen to them, you would not come to the

31· · conclusion that the inspectors were brutal, and

32· · we were certainly not angry about what

Page 6873·1· · happened.

·2· · · · · · · · · ·Q. To follow up on your answer,

·3· · were you concerned that your approach to the

·4· · interviews with Ms. Crombez made her

·5· · uncomfortable to the point that she could not

·6· · recall information?

·7· · · · · · · · · ·A. No.

·8· · · · · · · · · ·Q. Can you go to Tab 1 of the

·9· · yellow document that you've got there, the

10· · yellow-covered document.· That's

11· · Document 43510.· Just waiting for it to be

12· · pulled up.

13· · · · · · · · · ·A. Mm-hm.

14· · · · · · · · · ·Q. This is a document called an

15· · "Inspection Plan," and it seems to be a

16· · document that you can sort of fill in fields

17· · for as you go along; is that fair to say?

18· · · · · · · · · ·A. Yes.

19· · · · · · · · · ·Q. What's the purpose of this

20· · document?

21· · · · · · · · · ·A. Create an Inspection Plan.

22· · · · · · · · · ·Q. Does it have to be approved

23· · by anybody, for example?

24· · · · · · · · · ·A. No.

25· · · · · · · · · ·Q. Okay.· This is just to

26· · organize your thoughts before you go into a

27· · home for any given inspection?

28· · · · · · · · · ·A. Yes, because when you plan

29· · for something, you usually do a better job at

30· · it.

31· · · · · · · · · ·Q. And the Ministry actually

32· · contemplates that you should be planning

Page 6874·1· · because they've got a form that you've got to

·2· · fill out?

·3· · · · · · · · · ·A. I have to fill out a plan.

·4· · · · · · · · · ·Q. Right.· There's a very

·5· · detailed -- this is the Inspection Plan with

·6· · respect to your October 2016 inspection at

·7· · Caressant Care; is that correct?

·8· · · · · · · · · ·A. Yes.

·9· · · · · · · · · ·Q. All right.· It's a very

10· · detailed list of documents.· Would you agree

11· · with me?

12· · · · · · · · · ·A. Yes.

13· · · · · · · · · ·Q. It's more detailed than an

14· · RQI inspection, it appears?

15· · · · · · · · · ·A. CCF inspection is different

16· · than an RQI.

17· · · · · · · · · ·Q. With respect to the

18· · documentation, it appears to be more detailed

19· · than the documentation you would require for an

20· · RQI inspection; is that fair to say?

21· · · · · · · · · ·A. Yes, because this was a

22· · highly unusual situation.· It had never been

23· · done before.· Hopefully never does again.

24· · · · · · · · · ·And as I said yesterday, we have

25· · never started out with collecting an employee's

26· · entire employee file and started with a record

27· · review before we went into the home and started

28· · inspecting.· That was a highly unusual practice

29· · in a highly unusual situation.

30· · · · · · · · · ·Q. Well, that actually helps in

31· · terms of my next question.· Do you think there

32· · might be a value in the RQI process having some

Page 6875·1· · sort of a pre-review of any employees' files

·2· · who have been subject to discipline at the home

·3· · since the last RQI review?

·4· · · · · · · · · ·A. That's not our practice. I

·5· · would say that that would mean that our

·6· · inspection was not resident-focused because our

·7· · inspections are resident-focused.

·8· · · · · · · · · ·When we do an RQI, we randomly

·9· · select 40 residents to do a record review and

10· · an interview and an observation, and we're

11· · staying focused on the residents.· To start out

12· · with a staff employee file review, I think

13· · isn't resident-focused.

14· · · · · · · · · ·Q. But you would agree with me

15· · that upon your review of Ms. Wettlaufer's file

16· · in the October 2016 inspection, you uncovered a

17· · number of issues as between her and various

18· · residents at the home?

19· · · · · · · · · ·A. Yes, we did.

20· · · · · · · · · ·Q. So in a certain way, could

21· · you not deem that to be resident-focused?

22· · · · · · · · · ·A. That -- you can't compare --

23· · it's apples to -- it's apples to Volkswagens.

24· · I don't think it's the same thing.

25· · · · · · · · · ·Q. Well, I don't think it's the

26· · same thing either.· What I'm suggesting is

27· · could you supplement the RQI inspection process

28· · by having a pre-review of any employees who

29· · have been subject to discipline at the home

30· · since the last RQI process?

31· · · · · · · · · ·A. All I can say is no idea

32· · should be off the table, so it's worth

Page 6876·1· · consideration.

·2· · · · · · · · · ·Q. You talk --

·3· · · · · · · · · ·A. It seems so far out of my

·4· · normal practice and the program that I know.

·5· · My first instinct is to say no, but that's

·6· · because of the place that I'm coming from in

·7· · my -- in my world.· So it just seems really --

·8· · it's outside the box for me.· But could it be

·9· · considered?· Sure.

10· · · · · · · · · ·Q. Is it fair to say when you

11· · conducted your review, you were surprised with

12· · the nature of the discipline for medication

13· · administration errors?

14· · · · · · · · · ·A. Can you say that again?

15· · Sorry.· I need to focus.

16· · · · · · · · · ·Q. When you conducted your

17· · review of Ms. Wettlaufer' employment file, is

18· · it fair to say that you were surprised with the

19· · nature of the discipline she was given for her

20· · medication administration errors?

21· · · · · · · · · ·A. No.

22· · · · · · · · · ·Q. Were you surprised with what

23· · you had read given -- let's actually -- let me

24· · start again.

25· · · · · · · · · ·During the course of this

26· · Inspection Plan, you wanted to review the

27· · home's compliance history; is that fair?

28· · · · · · · · · ·A. We always take the

29· · complaint's history with us when we do an

30· · inspection, and it's part of the decision

31· · making and the judgment matrix as to what we're

32· · going to be issuing once we've identified a

Page 6877·1· · finding of noncompliance.

·2· · · · · · · · · ·Q. So if you can go to page 5 of

·3· · this document and just cycle down to the

·4· · bottom.· Perfect.

·5· · · · · · · · · ·So what I see here is a review

·6· · of the licensee's compliance history in the

·7· · long-term care home, and then there are a

·8· · series of pages that follow.

·9· · · · · · · · · ·A. Yes.

10· · · · · · · · · ·Q. Obviously you knew this

11· · before going into the home and before

12· · inspecting records at that time?

13· · · · · · · · · ·A. Yes, but I can't say that I

14· · review the compliance history in detail and put

15· · it to memory to be able to use that to further

16· · impact my inspection.

17· · · · · · · · · ·Q. I didn't suggest that.

18· · · · · · · · · ·A. No, that's just kind of where

19· · my mind went.

20· · · · · · · · · ·Q. I didn't suggest that, and

21· · I'm not meaning to suggest that.

22· · · · · · · · · ·A. Right.

23· · · · · · · · · ·Q. When you list out all of

24· · these circumstances where there's questions of

25· · a compliance order or a written notification or

26· · a VPC, what's the purpose of listing all of

27· · these things out?

28· · · · · · · · · ·A. We don't do this anymore.

29· · · · · · · · · ·Q. What was the purpose of

30· · listing all of these things out?

31· · · · · · · · · ·A. It was a record of the

32· · history of noncompliance in the home that was

Page 6878·1· · attached to the end of all of our Inspection

·2· · Plan templates.

·3· · · · · · · · · ·Because before that, we didn't

·4· · pull Cognos reports, so that's what we used

·5· · before.· Now we just pull the -- we get the

·6· · administrative assistants to pull a Cognos

·7· · report.· This was just our means of record

·8· · keeping.

·9· · · · · · · · · ·Q. Presumably there's a reason

10· · why the Ministry at that time asked you to

11· · include a compliance history.· And I'm asking

12· · you, do you know what that reason is?

13· · · · · · · · · ·A. Yes, I thought I just

14· · answered that.· It's -- once we find a finding

15· · of noncompliance and we need to decide what

16· · we're going to be issuing, that gets taken into

17· · consideration when we're completing the

18· · judgment matrix.

19· · · · · · · · · ·Q. Okay.· So there is a reason.

20· · And I didn't follow that from your last answer.

21· · The purpose here is to inform your judgment

22· · matrix when you're in the home?

23· · · · · · · · · ·A. Well, we could be out of the

24· · home.

25· · · · · · · · · ·Q. To inform your judgment

26· · matrix when you're conducting the inspection

27· · ultimately?

28· · · · · · · · · ·A. That's after we've completed

29· · the inspection, have determined there is a

30· · finding of noncompliance, and then we need to

31· · decide what we're going to be issuing as far as

32· · a WN, a VPC, or a CO.

Page 6879·1· · · · · · · · · ·Q. I don't think we're speaking

·2· · past each other here.· I think we're on the

·3· · same page.

·4· · · · · · · · · ·A. Okay.· Sorry.· I'm not

·5· · getting that.

·6· · · · · · · · · ·Q. Actually, we are.· We are.

·7· · · · · · · · · ·To what extent does the history

·8· · that you see here, regardless of whether you

·9· · review it in depth or not, inform the way you

10· · conduct an inspection?· Do you look for

11· · particular issues because what you've seen in a

12· · compliance history?

13· · · · · · · · · ·A. No.· And that's what I was

14· · saying before.· No, we don't.

15· · · · · · · · · ·Q. If a home has a longer

16· · compliance history or a more detailed

17· · compliance history or a more severe compliance

18· · history, that doesn't affect in any way the way

19· · you approach the inspection?

20· · · · · · · · · ·A. I approach every single

21· · inspection that I do going into the home,

22· · looking for evidence that the home has been

23· · compliant with the legs and the regs regardless

24· · of their history, because I need to be

25· · objective in looking -- gathering all the

26· · information that I need based on the

27· · legislation to make an objective decision based

28· · on the legislation --

29· · · · · · · · · ·Q. Given the --

30· · · · · · · · · ·A. -- with the information that

31· · I have at that time.

32· · · · · · · · · ·Q. I didn't mean to speak over

Page 6880·1· · you.

·2· · · · · · · · · ·A. That's okay.· Sorry.· I kept

·3· · going.

·4· · · · · · · · · ·Q. That's actually not how it's

·5· · supposed -- I'm supposed to wait for you to

·6· · end, and then I'm supposed to...

·7· · · · · · · · · ·Given what you ultimately found

·8· · in October 2016 and the variety of compliance

·9· · orders -- the variety of instances of

10· · noncompliance you found, did you find it

11· · unusual -- did you find it an unusually high

12· · amount of noncompliance given what you had seen

13· · in the history here in your Inspection Plan?

14· · · · · · · · · ·A. I would say you can't just

15· · say that in and of itself because we inspected

16· · a lot of things in that home.· We did more than

17· · the usual.· We had two follow-ups.· The more --

18· · I'm thinking more than 20 critical incidents,

19· · and I think there was at least 5 complaints.

20· · · · · · · · · ·And we were in the home

21· · November, December, January, February, and into

22· · March.· And we did the medication IP in its

23· · entirety.

24· · · · · · · · · ·And given all of that

25· · information, was I surprised, and given the

26· · state of the home at that time?· No.

27· · · · · · · · · ·Q. Can you go to Tab 2 of the

28· · document I've just given you, that

29· · yellow-covered document.· And this is

30· · Document 39100.

31· · · · · · · · · ·A. Yes.

32· · · · · · · · · ·Q. This is the order of the

Page 6881·1· · director, the mandatory management order that

·2· · Ms. Simpson issued.

·3· · · · · · · · · ·A. Yes.

·4· · · · · · · · · ·Q. I'm wondering if at any time

·5· · before this order was issued you had any input

·6· · on its content?

·7· · · · · · · · · ·A. I made the director referral

·8· · to the director that led to her making this

·9· · decision.· And I had regular weekly, if not

10· · more, contact with the director about what was

11· · happening in this home because she needed to

12· · know.

13· · · · · · · · · ·Q. I want to be clear.· That was

14· · clear from yesterday's evidence and your

15· · Affidavit.

16· · · · · · · · · ·A. Yeah.

17· · · · · · · · · ·Q. I'll be more precise in my

18· · question.· There's language here in this order,

19· · and I'm wondering if that language was vetted

20· · by you or you had any input into the narratives

21· · that are discussed in this order?

22· · · · · · · · · ·A. Can you give me an example of

23· · one of those narratives?

24· · · · · · · · · ·Q. Sure.· Can you go to page 4,

25· · please.· Actually, I apologize.· Can you go to

26· · page 8?· And just cycle down to the bottom.

27· · Perfect.· Thank you.

28· · · · · · · · · ·At page 8, there's a heading

29· · that says "Licensee Inability to Achieve and

30· · Sustain Compliance."· And the language below,

31· · it says:· [AS READ]

32· · · · · · · · · ·"The licensee has demonstrated a

Page 6882·1· · · · · · · · · ·continued inability to fully

·2· · · · · · · · · ·understand the scope and

·3· · · · · · · · · ·severity of noncompliance and

·4· · · · · · · · · ·the issues involved, as well as

·5· · · · · · · · · ·what actions are required and

·6· · · · · · · · · ·what resources and effort are

·7· · · · · · · · · ·needed to be in place at the

·8· · · · · · · · · ·home to comply with the

·9· · · · · · · · · ·compliance orders."

10· · Do you see that?

11· · · · · · · · · ·A. Yes.

12· · · · · · · · · ·Q. That's specific language, and

13· · I'm wondering if you were consulted with

14· · respect to that language.

15· · · · · · · · · ·A. This is the orders of the

16· · director, so she wrote them, but I can say that

17· · when I make the director referral, that's my

18· · opportunity to give the director information

19· · that might have led to her creating the -- that

20· · definitely led to her creating this.

21· · · · · · · · · ·Q. Okay.

22· · · · · · · · · ·A. So the director referral also

23· · gives the director information that's not

24· · necessarily captured in the inspection report

25· · itself.· So, for example, management turnover

26· · or other things that are happening in the home

27· · that might not have been captured in the

28· · report.

29· · · · · · · · · ·Because the director has to make

30· · this incredible decision that has huge

31· · implications, and she wasn't the one who did

32· · the inspection.· She wasn't in the home.

Page 6883·1· · · · · · · · · ·So I need to give her all the

·2· · information I can about my experience in that

·3· · home.· And that's how we do it, through the

·4· · director referral.· That's where I give her

·5· · this information.

·6· · · · · · · · · ·Q. I understand.· This mandatory

·7· · management order has a series of criticisms

·8· · with respect to those at Caressant Care

·9· · Woodstock who were responsible for managing the

10· · home.· Would you agree with that?

11· · · · · · · · · ·A. It stated the facts.

12· · · · · · · · · ·Q. I asked Ms. Simpson two

13· · questions during my cross-examination that I'm

14· · going to ask you.

15· · · · · · · · · ·As of September 1, 2017, did you

16· · feel that Caressant Care Woodstock had a full

17· · understanding of how to comply with the act?

18· · · · · · · · · ·A. No.

19· · · · · · · · · ·Q. And as of September 1, 2017,

20· · did you feel that Caressant Care Woodstock had

21· · a full understanding of its reporting

22· · obligations under the act?

23· · · · · · · · · ·A. I would have to say yes,

24· · because -- I'd have to -- no, maybe I'd have to

25· · go back and look because we did issue duty to

26· · report, and we did comply it.· But at this

27· · moment, I can't recall when that was -- when

28· · that was complied.

29· · · · · · · · · ·So if it was complied after

30· · September 1st, then the answer is no.· If it

31· · was complied before September 1st, then the

32· · answer is yes.· And I can't recall at this

Page 6884·1· · time.· Because it wouldn't be fair for me to

·2· · say they didn't have an understanding when I

·3· · had just complied that order.

·4· · · · · · · · · ·Q. Yesterday, we were talking

·5· · about what your hope is that long-term care

·6· · homes -- essentially that you're not looking to

·7· · nitpick, but you just want to have confidence

·8· · that management was doing its best.· Do you

·9· · remember talking about that yesterday?

10· · · · · · · · · ·A. I wouldn't say it in those

11· · words.

12· · · · · · · · · ·Q. How would you say it? I

13· · don't want to unfairly frame your words.

14· · · · · · · · · ·A. Can you -- can you say what

15· · you just said again?

16· · · · · · · · · ·Q. I'm not sure I can, but I'm

17· · going to try.

18· · · · · · · · · ·During your testimony yesterday,

19· · I understood you to say that you don't like to

20· · nitpick, but your big picture is that you're

21· · just hoping that management is doing its best

22· · with respect to meeting its obligations under

23· · the act.

24· · · · · · · · · ·A. I would say that's totally

25· · not what I said or not what I intended to say.

26· · · · · · · · · ·Q. Okay.

27· · · · · · · · · ·A. And I would never use the

28· · word "nitpick," and I'm not saying that you --

29· · you are saying that.

30· · · · · · · · · ·Q. You didn't use the word

31· · "nitpick."· I said nitpick.

32· · · · · · · · · ·A. Yeah, that's what I'm saying.

Page 6885·1· · You -- but I'm -- okay.· Let's just move on.

·2· · · · · · · · · ·I look for evidence to support

·3· · compliance.· There's nothing nitpicky.· Like,

·4· · I -- that's all I can say about that is I look

·5· · for evidence to support compliance.

·6· · · · · · · · · ·And sure, personally, I hope the

·7· · home is doing their best, but I don't go in

·8· · with, "Gee, I hope they're doing their best,"

·9· · and, "Gee, I really think they did their best,

10· · so I'm good to go."

11· · · · · · · · · ·That's not how I look at

12· · inspections.· I always need to have evidence to

13· · support compliance or noncompliance.

14· · · · · · · · · ·Q. Can you go to Tab 4 of the

15· · documents that you have.· This is

16· · Document 43372.· This is the inspection report

17· · dated both January 24th and August 15th.

18· · · · · · · · · ·My first question with respect

19· · to your inspection deals with your interviews

20· · with staff.

21· · · · · · · · · ·Yesterday, you talked about how

22· · during the course of your interviews with

23· · staff, no one sort of raised an issue that they

24· · had any concerns or any suspicions with respect

25· · to Ms. Wettlaufer.· Have I characterized that

26· · properly?

27· · · · · · · · · ·A. They obviously had concerns

28· · because we talked to the staff who had written

29· · concerns --

30· · · · · · · · · ·Q. I'll rephrase my question --

31· · · · · · · · · ·A. -- but not concerns that she

32· · had murdered people.

Page 6886·1· · · · · · · · · ·Q. Okay.· During the course of

·2· · your conversation with Ms. Routledge or anybody

·3· · else, do you remember anyone referring to

·4· · Ms. Wettlaufer as an angel of death?

·5· · · · · · · · · ·A. Yes.

·6· · · · · · · · · ·Q. They said that during the

·7· · course of your interviews?

·8· · · · · · · · · ·A. One of them did.

·9· · · · · · · · · ·Q. And just to understand that a

10· · bit better, in what context did they tell you

11· · that Ms. Wettlaufer was an angel of death?

12· · · · · · · · · ·A. I'd have to go back and look

13· · at that interview.

14· · · · · · · · · ·Q. During the course of

15· · Ms. Routledge's testimony, she said that this

16· · comment was raised to her by another person

17· · working at the home, Ms. Laycock, because

18· · Ms. Laycock had some current concerns about how

19· · Ms. Wettlaufer was conducting herself with

20· · palliative residents, essentially telling them

21· · it was okay to let go and that Ms. Laycock was

22· · offended by it.

23· · · · · · · · · ·During the course of your

24· · interviews in October 2016, were any issues of

25· · that sort raised to you?

26· · · · · · · · · ·A. I'd have to go back and look

27· · at the interviews.· I'm sorry.· That's more

28· · detail than I'm aware of at this time.· We did

29· · a lot of interviews, and they were pretty long.

30· · · · · · · · · ·Q. I understand.· Can you go to

31· · page 11 of the document.· There are numbered

32· · pages on the bottom right-hand side if that

Page 6887·1· · helps.

·2· · · · · · · · · ·Yesterday, you were speaking

·3· · with Ms. Stephens -- can you cycle down just a

·4· · little bit?· Perfect.· Thank you.

·5· · · · · · · · · ·You'd been talking with

·6· · Ms. Stephens about how both the medical

·7· · director, the administrator, and the Director

·8· · of Nursing had not participated in any

·9· · medication management system program

10· · evaluations for significant periods of time,

11· · and in the case of the medical director, almost

12· · 40 years.

13· · · · · · · · · ·Did you first -- my first

14· · question to you is did you find that unusual?

15· · · · · · · · · ·A. Yes.

16· · · · · · · · · ·Q. Why?

17· · · · · · · · · ·A. Because the legislation

18· · requires them to do that.

19· · · · · · · · · ·Q. Did you consider that a

20· · serious issue of noncompliance?

21· · · · · · · · · ·A. I'd have to go down and look

22· · at what I issued for that.

23· · · · · · · · · ·Q. Let's not do that so we can

24· · keep going.

25· · · · · · · · · ·Let's go to page 2 of this same

26· · document.· There's a discussion of an unusual

27· · or accidental death with respect to Mr. Silcox.

28· · Do you see that at the bottom?

29· · · · · · · · · ·A. Yes.

30· · · · · · · · · ·Q. My question to you is as an

31· · inspector -- I'm just looking for your

32· · experience as an inspector on the ground.

Page 6888·1· · · · · · · · · ·Are the reports of unusual

·2· · occurrences for an unexpected death -- do they

·3· · typically align with what the coroner is given

·4· · in terms of information?

·5· · · · · · · · · ·A. I would have no way to know

·6· · that.

·7· · · · · · · · · ·Q. Okay.· So to your knowledge,

·8· · during the course of your inspection, there's

·9· · no sort of cross-referencing between the

10· · information that is provided to the coroner

11· · with respect to an unexpected death and what

12· · the Ministry standard is with respect to an

13· · unexpected death and if it should be reported?

14· · · · · · · · · ·A. I have no idea.

15· · · · · · · · · ·Q. Okay.· Before this inspection

16· · report, would you have considered

17· · Caressant Care's inspection history to be

18· · average when compared to other homes?

19· · · · · · · · · ·A. I don't know.

20· · · · · · · · · ·Q. If Caressant Care's

21· · experience was average -- and I know that's a

22· · big "if" -- given all of the compliance issues

23· · you found in this inspection report, do you

24· · think this has any implications for how the

25· · effective the Ministry's inspection regime is

26· · in achieving its goals?

27· · · · · · · · · ·A. No.

28· · · · · · · · · ·Q. If you look at page 3 of this

29· · document, there's a reference to -- cycle down,

30· · please.· Thank you.· A little bit up.

31· · · · · · · · · ·This is a reference to the

32· · insulin overdose on October the 7th, 2007, that

Page 6889·1· · you talked about with Ms. Stephens yesterday?

·2· · · · · · · · · ·A. Yes.

·3· · · · · · · · · ·Q. We now know that insulin

·4· · overdose is in connection with Ms. Adriano?

·5· · · · · · · · · ·A. Yes.

·6· · · · · · · · · ·Q. I'd like you to turn to

·7· · Tab 5, please, of the document you have, which

·8· · is Document 16924.

·9· · · · · · · · · ·A. Yes.

10· · · · · · · · · ·Q. Just got to wait for it to

11· · get pulled up.

12· · · · · · · · · ·A. Mm-hm.

13· · · · · · · · · ·Q. And can you shrink it a

14· · little bit?· Perfect.· And cycle down, please.

15· · Thank you.· If you could actually highlight the

16· · bar that says October 1st, that whole week all

17· · the way across.· Thanks.

18· · · · · · · · · ·So this has been acknowledged by

19· · Ms. Crombez earlier in these proceedings to be

20· · Ms. Wettlaufer's time sheet for that time?

21· · · · · · · · · ·A. Yes.

22· · · · · · · · · ·Q. So I'm, again, asking for

23· · your experience as an inspector.· In your

24· · opinion, if an inspector saw that

25· · Ms. Wettlaufer was working a double shift on

26· · October the 6th -- and, of course, this would

27· · obviously be after a report had been filed --

28· · do you think you would have interviewed her?

29· · · · · · · · · ·A. Say that one more time.

30· · · · · · · · · ·MR. VAN KRALINGEN:· I'm going to

31· · · · · · · · · ·rephrase my question, and then

32· · · · · · · · · ·you can object.

Page 6890·1· · · · · · · · · ·BY MR. VAN KRALINGEN:

·2· · · · · · · · · ·Q. Baby steps.· If

·3· · Caressant Care had filed some sort of a

·4· · critical incident report with respect to the

·5· · overdose of insulin with Ms. Adriano, an

·6· · inspector would have been dispatched; is that

·7· · fair to say?

·8· · · · · · · · · ·A. I --

·9· · · · · · · · · ·MR. GOLDEN:· I'd like to, with

10· · · · · · · · · ·respect, state my concern right

11· · · · · · · · · ·now.· We're talking -- and I

12· · · · · · · · · ·thought this was clarified

13· · · · · · · · · ·yesterday -- about an event that

14· · · · · · · · · ·happened in 2007 under the

15· · · · · · · · · ·Nursing Homes Act.

16· · · · · · · · · · · There was no critical

17· · · · · · · · · ·incident reports, and I don't

18· · · · · · · · · ·believe that this witness -- and

19· · · · · · · · · ·I think we clarified it

20· · · · · · · · · ·yesterday -- has any experience

21· · · · · · · · · ·being an inspector training or

22· · · · · · · · · ·understanding how these kinds of

23· · · · · · · · · ·matters were inspected and

24· · · · · · · · · ·responded to in 2007 under the

25· · · · · · · · · ·old regime.

26· · · · · · · · · ·BY MR. VAN KRALINGEN:

27· · · · · · · · · ·Q. If you were called with

28· · respect to a medication incident -- and I'm

29· · talking about in the "if" at this point.

30· · · · · · · · · ·If you were called with respect

31· · to a medication incident where a resident was

32· · sent to hospital, would one of the documents

Page 6891·1· · you looked at be a time sheet identifying who

·2· · was working on shift at the time the medication

·3· · incident may have occurred?

·4· · · · · · · · · ·THE COMMISSIONER:· Are you

·5· · · · · · · · · ·speaking about now?

·6· · · · · · · · · ·MR. VAN KRALINGEN:· I'm talking

·7· · · · · · · · · ·about right now in the immediate

·8· · · · · · · · · ·moment.

·9· · · · · · · · · ·THE COMMISSIONER:· And I don't

10· · · · · · · · · ·understand the question then.

11· · · · · · · · · ·If she were called?

12· · · · · · · · · ·MR. VAN KRALINGEN:· If an

13· · · · · · · · · ·inspector is -- I just want her

14· · · · · · · · · ·experience as to what an

15· · · · · · · · · ·inspector would do in the

16· · · · · · · · · ·circumstance where a medication

17· · · · · · · · · ·incident that led to

18· · · · · · · · · ·hospitalization occurred.

19· · · · · · · · · ·THE COMMISSIONER:· Okay.· In --

20· · · · · · · · · ·today?

21· · · · · · · · · ·MR. VAN KRALINGEN:· Today.

22· · · · · · · · · ·We'll just talk about today.

23· · · · · · · · · ·THE COMMISSIONER:· So as an

24· · · · · · · · · ·inspector, if they get a -- what

25· · · · · · · · · ·is it?· A complaint or a

26· · · · · · · · · ·critical incident?

27· · · · · · · · · ·MR. VAN KRALINGEN:· It would be

28· · · · · · · · · ·a critical incident report about

29· · · · · · · · · ·a medication error that led to

30· · · · · · · · · ·hospitalization.

31· · · · · · · · · ·BY MR. VAN KRALINGEN:

32· · · · · · · · · ·Q. Let's assume you're an

Page 6892·1· · inspector in that moment and you attend, would

·2· · one goal be to identify the staff member who

·3· · may have been responsible for that medication

·4· · error?

·5· · · · · · · · · ·A. Yes.

·6· · · · · · · · · ·Q. In a sense trite question,

·7· · but why would that be a goal?

·8· · · · · · · · · ·A. Because that would be part of

·9· · information gathering.

10· · · · · · · · · ·Q. And you would have had the

11· · power as an inspector to pull a document such

12· · as an employee time sheet?

13· · · · · · · · · ·A. Yes.

14· · · · · · · · · ·Q. Okay.· Can you go to Tab 9

15· · again, which is the medication inspection

16· · protocol, and, again, that's Document 39398.

17· · And I'm asking you to look at page 5 of that

18· · document.· At the top -- cycle up just a little

19· · bit.· Cycle down just a little bit, sorry.

20· · Thanks.

21· · · · · · · · · ·Right in the middle near the end

22· · of that first paragraph, the sentence --

23· · · · · · · · · ·A. I'm not on the same page as

24· · you.· I'm sorry to interrupt.

25· · · · · · · · · ·Q. That's all right.· It's also

26· · my last question if that incentivizes you.

27· · · · · · · · · ·A. I found it.· Before, I was

28· · one behind, and this time I was one after. I

29· · got it now.

30· · · · · · · · · ·Q. Okay.· Second last bullet

31· · point says:· [AS READ]

32· · · · · · · · · ·"The RN resigned prior to the

Page 6893·1· · · · · · · · · ·staff realizing that the

·2· · · · · · · · · ·medication was missing.· She

·3· · · · · · · · · ·gave two weeks' notice and took

·4· · · · · · · · · ·the two weeks as sick time."

·5· · My simple question to you is if the home had

·6· · terminated her employment, is that something

·7· · that you would have documented?

·8· · · · · · · · · ·A. Yes.

·9· · · · · · · · · ·MR. VAN KRALINGEN:· Okay.· Those

10· · · · · · · · · ·are all of my questions.

11· · · · · · · · · ·Thank you for your time today.

12· · · · · · · · · ·THE WITNESS:· Thank you.

13· · · · · · · · · ·MR. SCOTT:· Good morning,

14· · · · · · · · · ·Commissioner.

15· · · · · · · · · ·THE COMMISSIONER:· Good morning,

16· · · · · · · · · ·Mr. Scott.

17· · · · · · · · · ·CROSS-EXAMINATION BY MR. SCOTT:

18· · · · · · · · · ·Q. Morning, Rhonda.

19· · · · · · · · · ·A. Morning.

20· · · · · · · · · ·Q. I'm Paul Scott.· I also

21· · represent one of the family groups, and I have

22· · a few questions for you this morning.

23· · · · · · · · · ·Is it fair to say that really

24· · the sole purpose of your inspections is to

25· · ensure the safety and security of residents in

26· · long-term care homes?

27· · · · · · · · · ·A. The goal of our program is to

28· · ensure the safety and security of residents in

29· · long-term care homes, and we do that by

30· · gathering information to determine if the home

31· · has been compliant with the legislation.

32· · · · · · · · · ·Q. Okay.· That's because you

Page 6894·1· · want to make sure that the people who are

·2· · living in those homes -- and we've established

·3· · that that is their home.· It's not a hotel or

·4· · not a hospital.· You want to make sure their

·5· · lives are as good as they can be; correct?

·6· · · · · · · · · ·A. Yes.

·7· · · · · · · · · ·Q. If I'm misstating it, please

·8· · tell me.

·9· · · · · · · · · ·A. No.

10· · · · · · · · · ·Q. Okay.· You were a little

11· · hesitant.· I just wanted to make sure.

12· · · · · · · · · ·So I want to check on one thing.

13· · If you inspect a home and there's an agency

14· · nurse working at the time -- have you had that

15· · happen?

16· · · · · · · · · ·A. I'm sure it has.

17· · · · · · · · · ·Q. Okay.· And do you treat the

18· · agency nurse any differently than you would a

19· · staff nurse?

20· · · · · · · · · ·A. Do I treat them any

21· · differently?

22· · · · · · · · · ·Q. During your inspection.

23· · · · · · · · · ·A. No.· I kind of treat people

24· · the same.

25· · · · · · · · · ·Q. I appreciate that.· I mean

26· · more in your professional capacity.· Does it

27· · make any difference to you that she is or he is

28· · an agency nurse versus an employee of the home?

29· · · · · · · · · ·A. It's obviously going to

30· · impact -- it's the same line of thought when

31· · there's been a management change, so I'm not

32· · going to -- I can't expect that that agency

Page 6895·1· · nurse, if the case is that they are working one

·2· · shift and haven't worked in that home before,

·3· · are going to be able to speak to something that

·4· · happened months ago.

·5· · · · · · · · · ·Q. Well, that's fair.· And so it

·6· · is a little bit of a different metric that you

·7· · use with that nurse?

·8· · · · · · · · · ·A. It's something I'll take into

·9· · consideration.

10· · · · · · · · · ·Q. Okay.· And is it ever the

11· · case that you have to contact their agency and

12· · get additional information about that nurse

13· · from the agency versus the home?

14· · · · · · · · · ·A. I did that about a month ago.

15· · · · · · · · · ·Q. I'm sorry?

16· · · · · · · · · ·A. I did that about a month ago.

17· · · · · · · · · ·Q. Okay.· So it does happen?

18· · · · · · · · · ·A. Yes.

19· · · · · · · · · ·Q. What sort of information

20· · would you ask the agency for with respect to

21· · that nurse?

22· · · · · · · · · ·A. It depends on the inspection

23· · and what information I'm gathering.

24· · · · · · · · · ·Q. Okay.· Well, what about a

25· · month ago?· What sort of information were you

26· · looking for?

27· · · · · · · · · ·A. I was looking at who does

28· · criminal reference checks, how they screen

29· · their employees, who does the training and

30· · orientation.

31· · · · · · · · · ·And I wanted to know in that

32· · case what shifts that the agency had provided

Page 6896·1· · to the home, and I wanted to know when they

·2· · were booked.

·3· · · · · · · · · ·Because when you're looking at

·4· · Section 8 and the 24/7 RN and you're trying to

·5· · determine if they used the agency in an

·6· · emergency, if that agency got booked three

·7· · weeks before, emergencies usually aren't

·8· · anticipated three weeks ahead of time.

·9· · · · · · · · · ·Q. Sort of the definition of

10· · emergency, isn't it?

11· · · · · · · · · ·A. Kind of.

12· · · · · · · · · ·Q. Yeah.· Okay.· Any other

13· · reasons why you might contact the agency?

14· · · · · · · · · ·A. There could be.

15· · · · · · · · · ·Q. Okay.· But you can't think of

16· · any right now?

17· · · · · · · · · ·A. I'm sure there could be, but,

18· · again, it's always going to depend on the

19· · information that I have and the inspection that

20· · I'm doing.· And there are billions of different

21· · scenarios, so it's hard to say.

22· · · · · · · · · ·Q. Okay.· I appreciate that.

23· · · · · · · · · ·So you touched on contacting the

24· · agency about their credentials.· When you go

25· · into the home to inspect, do you check on the

26· · credentials of the staff in the home as well?

27· · · · · · · · · ·A. If my inspection takes me

28· · there, yes.

29· · · · · · · · · ·Q. What would precipitate your

30· · inspection going there?

31· · · · · · · · · ·A. We did at Caressant Care

32· · Woodstock, and we issued findings of

Page 6897·1· · noncompliance because they hadn't had their

·2· · criminal reference checks.· There was some

·3· · staff.· And --

·4· · · · · · · · · ·Q. I just want to stop you

·5· · there.· Is this after the Elizabeth Wettlaufer

·6· · crimes came to light --

·7· · · · · · · · · ·A. Yes.

·8· · · · · · · · · ·Q. -- or before?

·9· · · · · · · · · ·A. After.

10· · · · · · · · · ·Q. Okay.· In a normal course of

11· · an inspection, though, do you check the

12· · credentials of staff working in a home?

13· · · · · · · · · ·A. We have received -- I know

14· · our office has received complaints where they

15· · questioned -- or they have called and

16· · complained and said, "This home is hiring

17· · staff, and they're working before they hand in

18· · their criminal reference check."

19· · · · · · · · · ·And in that case, an inspection

20· · would be done.· And that's when we'd look at

21· · that.· There's probably lots of other

22· · scenarios, but that's one example.

23· · · · · · · · · ·Q. Okay.· But that's triggered

24· · by an outside force.· Somebody complains or

25· · makes a complaint.· But do you, as an

26· · inspector, go in and say to the administrator,

27· · "I'd like to see the credentials of your

28· · staff"?

29· · · · · · · · · ·A. As in with the EW, we had a

30· · reason to go there, so we did.· If you're -- I

31· · can't give you an example right now of a

32· · situation where I would do that.

Page 6898·1· · · · · · · · · ·Q. I'm not sure I need an

·2· · example.· What I'm simply asking is the

·3· · Elizabeth Wettlaufer investigation was unique.

·4· · I think we can all agree on that?

·5· · · · · · · · · ·A. Yes.

·6· · · · · · · · · ·Q. In the normal course, in your

·7· · time as an inspector, have you ever gone into a

·8· · home and asked to see the credentials of the

·9· · nursing staff?

10· · · · · · · · · ·A. Yes.

11· · · · · · · · · ·Q. Okay.· And is that

12· · precipitated by something, or have you done

13· · that just as a normal part of your inspection?

14· · · · · · · · · ·A. All of my actions are

15· · precipitated by something.

16· · · · · · · · · ·Q. Okay.· And that is one of my

17· · questions.· All of your actions are actually a

18· · reaction to something; is that correct?· You've

19· · had a complaint.· Somebody has told you to do

20· · something versus I'm just going to look at

21· · particular documents?

22· · · · · · · · · ·A. No, because that's outside of

23· · the premise of stage 1 of the RQI.

24· · · · · · · · · ·Q. So you're not allowed to do

25· · that; is that correct?· Of your own volition,

26· · you can't just decide I'm going to check on

27· · things.· I'm going to check on their

28· · credentials?

29· · · · · · · · · ·A. That's not our practice.

30· · · · · · · · · ·Q. Can you do it?

31· · · · · · · · · ·A. That would be me not

32· · following my policy.

Page 6899·1· · · · · · · · · ·Q. Okay.· And have you ever

·2· · entered a nursing home after midnight to do an

·3· · inspection?

·4· · · · · · · · · ·A. I haven't, but I have

·5· · coworkers who have.

·6· · · · · · · · · ·Q. And were those coworkers --

·7· · do you know, were those coworkers instructed to

·8· · do that, or did they do that of their own

·9· · volition?

10· · · · · · · · · ·A. They did that of their own

11· · volition; however, again, out of respect for

12· · our manager and their position and our

13· · position, our manager would need to know that

14· · we're working at midnight.

15· · · · · · · · · ·She needs to know where her

16· · staff are.· She would need to know that there

17· · could be health and safety risks of travelling

18· · at night, in the middle of the night.

19· · · · · · · · · ·So we would never do that

20· · without discussing that with our manager, but

21· · it's my understanding that that inspector

22· · decided to do that based on the inspection that

23· · they were doing.

24· · · · · · · · · ·Q. Okay.· So it sounds to me

25· · like it's really one inspector that's done it

26· · that you know of; is that correct?

27· · · · · · · · · ·A. That's the one that comes to

28· · my mind right now.

29· · · · · · · · · ·Q. Fair enough.

30· · · · · · · · · ·A. I'm -- there have been

31· · others.· That's the one that's popping into my

32· · head at this time.

Page 6900·1· · · · · · · · · ·Q. But, again, that, as far as

·2· · you know, was as a result of an inspection that

·3· · was already taking place?

·4· · · · · · · · · ·A. Yes.· I see what you're

·5· · saying.

·6· · · · · · · · · ·Q. Yes.· So, again, I come back

·7· · to it's not really part of your policy to just

·8· · stop in or drop in on a nursing home at

·9· · 1 o'clock in the morning to check on things?

10· · · · · · · · · ·A. That is correct.

11· · · · · · · · · ·Q. So you have no direction from

12· · the Ministry to do that as an inspector?

13· · · · · · · · · ·A. That is correct.

14· · · · · · · · · ·Q. Do you think you have the

15· · authority to do that as an inspector?

16· · · · · · · · · ·A. No.

17· · · · · · · · · ·Q. Do you have the authority as

18· · an inspector to review all documentation that

19· · is in a home when you go in to inspect it?

20· · · · · · · · · ·A. Yes.

21· · · · · · · · · ·Q. And you've been asked about

22· · looking at employment records, and we know that

23· · you did for the Elizabeth Wettlaufer

24· · investigation.

25· · · · · · · · · ·Have you looked at employment

26· · records for any other inspection that you've

27· · done?

28· · · · · · · · · ·A. Yes.

29· · · · · · · · · ·Q. Okay.· And what precipitated

30· · you doing that?· Was it, again, medication

31· · errors?

32· · · · · · · · · ·A. The one that's popping into

Page 6901·1· · my head for a more recent one was incidents of

·2· · staff-to-resident abuse.

·3· · · · · · · · · ·Q. Okay.· And do inspectors ever

·4· · evaluate the appropriateness of staffing levels

·5· · in long-term care homes?

·6· · · · · · · · · ·A. Yes.

·7· · · · · · · · · ·Q. Okay.· And do you do that

·8· · with respect to RNs as well as PSWs, et cetera?

·9· · · · · · · · · ·A. The only legislation that I

10· · have related to RNs and the staffing levels is

11· · that the homes are required to have a minimum

12· · of one 24 hours a day, 7 days a week.

13· · · · · · · · · ·So we do look at that as a

14· · regular practice in an RQI.· And if our

15· · inspection takes us there or we have a

16· · complaint related to staffing, I would look

17· · there.

18· · · · · · · · · ·But staffing levels as far as

19· · Personal Support Workers, we -- because we

20· · don't have legislation that speaks to the

21· · number that they have to have, the staffing

22· · levels, whether they're appropriate or not, we

23· · don't necessarily have an opinion on the

24· · number.

25· · · · · · · · · ·It's all going to depend on is

26· · the home meeting the needs of the residents,

27· · and if their needs aren't being met, then we

28· · would ask the question, "Are your staffing

29· · levels appropriate to meet the needs of those

30· · residents at that time?"

31· · · · · · · · · ·Q. Okay.· And that's fair, but

32· · are you aware that at Caressant Care Woodstock,

Page 6902·1· · there was one RN on duty at night only?· Now,

·2· · in addition to that RN, there was an RPN, and

·3· · there may have been other PSW staff, but to be

·4· · clear, there's only one RN on.· Are you aware

·5· · of that?

·6· · · · · · · · · ·A. Yes.

·7· · · · · · · · · ·Q. In your mind, is that enough

·8· · RNs to be on staff at night?

·9· · · · · · · · · ·A. That's not for me to say.

10· · · · · · · · · ·Q. But you told me a moment ago

11· · that you decide on if the needs of the

12· · residents are being met by the staffing levels;

13· · is that correct?

14· · · · · · · · · ·A. Yes.

15· · · · · · · · · ·Q. And have you ever gone into

16· · that home after midnight to check and see

17· · whether their needs are being met by one RN?

18· · · · · · · · · ·A. No.

19· · · · · · · · · ·Q. So you wouldn't really know

20· · if it's happening or not, would you?

21· · · · · · · · · ·A. I would say that our program,

22· · given that we -- people have the opportunity to

23· · call the action line and voice complaints --

24· · that includes residents, families, and staff.

25· · And staff were very often -- make complaints to

26· · the action line when they have a concern about

27· · staffing.

28· · · · · · · · · ·We have critical incident

29· · reporting and mandatory reporting where if

30· · something happens as a result of an RN's

31· · actions, has an impact on residents, we would

32· · inspect on that.

Page 6903·1· · · · · · · · · ·And we go into every home every

·2· · year and randomly interview residents and ask

·3· · them a specific question:· "Do you feel there's

·4· · enough staff to meet your needs without having

·5· · to wait a long time?"

·6· · · · · · · · · ·We also ask them a number of

·7· · other questions that relates to pain.· And we

·8· · do multiple observations to determine if

·9· · they're receiving the appropriate care.

10· · · · · · · · · ·So I believe that those

11· · mechanisms serve to advise us enough to go in

12· · and do -- to determine if that was a problem.

13· · · · · · · · · ·Q. Okay.· And when you did your

14· · inspection of Caressant Care after

15· · Ms. Wettlaufer's crimes came to light, were you

16· · told that there was a locked filing cab in the

17· · basement with other documents?

18· · · · · · · · · ·A. No.

19· · · · · · · · · ·Q. When did you find out about

20· · that?

21· · · · · · · · · ·A. In court.

22· · · · · · · · · ·Q. Okay.· So at this hearing?

23· · · · · · · · · ·A. This hearing.· Yeah, I should

24· · say that.· I'm sorry.

25· · · · · · · · · ·Q. No, that's okay.

26· · · · · · · · · ·Do you feel like your hands are

27· · tied in any way as an inspector?· Do you feel

28· · like you can't do something you really would

29· · like to do?

30· · · · · · · · · ·A. No.

31· · · · · · · · · ·Q. And as an inspector, are you

32· · encouraged to provide your managers and others

Page 6904·1· · with any suggestions you might have about

·2· · improving the system of inspection in long-term

·3· · care homes?

·4· · · · · · · · · ·A. Very much.

·5· · · · · · · · · ·Q. Do you do that in writing, or

·6· · is it done verbally?

·7· · · · · · · · · ·A. Both.

·8· · · · · · · · · ·Q. Are they done at regular

·9· · meetings?

10· · · · · · · · · ·A. Yes.

11· · · · · · · · · ·Q. Okay.

12· · · · · · · · · ·A. And our director has put

13· · things in writing to say we welcome the

14· · opportunity for suggestions.· We've recently

15· · had -- there was a survey that came from the

16· · acting director asking if anyone would like to

17· · participate in different quality improvement

18· · groups, for lack of a better label for that,

19· · what's our -- what is our passion and our

20· · interest and what would we like to be involved

21· · with to provide input from the inspector

22· · perspective.· And I filled that out and said,

23· · "Yes, I want to do that."

24· · · · · · · · · ·Q. Okay.· Do you feel like the

25· · current legislation in any way ties your hands?

26· · · · · · · · · ·A. No, but I'm limited to be

27· · able to -- I can only issue noncompliance based

28· · on the legislation.

29· · · · · · · · · ·Q. I understand.

30· · · · · · · · · ·A. I can't act outside of the

31· · legislation.

32· · · · · · · · · ·Q. I appreciate that.· I'm not

Page 6905·1· · suggesting that you should.· I just want to

·2· · know if you, as an inspector, think that the

·3· · legislation is holding you back from doing

·4· · certain things that you'd like to do.

·5· · · · · · · · · ·A. No.· And as we said many,

·6· · many times, it's a really big book with a lot

·7· · of regulations in there.· There's a lot in

·8· · there to look at.

·9· · · · · · · · · ·Q. I appreciate that.

10· · · · · · · · · ·A. It's pretty broad.

11· · · · · · · · · ·Q. So I guess part of my

12· · question might be are there any regulations

13· · you'd like to see taken out of there?

14· · · · · · · · · ·A. I would never say that.

15· · · · · · · · · ·Q. Okay.· That's probably the

16· · right answer today.

17· · · · · · · · · ·Just on that point, I want to

18· · mention, you'd mentioned a few times the legs

19· · and regs.· And just for the public watching at

20· · home, you mean the legislation and the

21· · regulations; correct?

22· · · · · · · · · ·A. That is what I mean, yes.

23· · · · · · · · · ·Q. That's fair enough.

24· · · · · · · · · ·I didn't ask you one question.

25· · That is when you go into the homes and you do

26· · an inspection, do you look at the credentials

27· · of the administrators in the home?

28· · · · · · · · · ·A. If my inspection takes me

29· · there, yes.· And, yes, I have done that.

30· · · · · · · · · ·Q. Okay.· And do you make note

31· · of their credentials, or what do you do with

32· · that information?

Page 6906·1· · · · · · · · · ·A. I document all of my

·2· · information gathering in my IP.· Occasionally,

·3· · it's in an inspector logbook, but there would

·4· · be nothing in my logbook that wasn't in my IPs.

·5· · That's how we gather information.· That's how

·6· · we document all of our information.

·7· · · · · · · · · ·Q. In that course, would you

·8· · ever document that perhaps the administrator

·9· · wasn't as well trained as they should be?

10· · · · · · · · · ·A. Well, trained in what way?

11· · · · · · · · · ·Q. As an administrator for a

12· · long-term care home.

13· · · · · · · · · ·A. So I would look at the

14· · legislation related to the requirements for the

15· · qualifications of an administrator and gather

16· · information to determine if they were compliant

17· · with that legislation related to their

18· · qualifications.

19· · · · · · · · · ·Q. Okay.· And you'd make note of

20· · that --

21· · · · · · · · · ·A. Yes.

22· · · · · · · · · ·Q. -- one way or the other?

23· · Fair enough.

24· · · · · · · · · ·And my final question for you,

25· · you said to Mr. Van Kralingen when he was

26· · asking you about the mandatory order, and there

27· · were a list of issues that were put down the

28· · side.· Do you recall that?

29· · · · · · · · · ·A. Yes.

30· · · · · · · · · ·Q. And he'd asked you if you

31· · thought that was an unusual amount or if you

32· · were surprised by it.· Again, I'm paraphrasing.

Page 6907·1· · And you had said to him, "Given the state of

·2· · the home at the time, no."

·3· · · · · · · · · ·And I wondered, in your mind,

·4· · what was the state of the home at that time?

·5· · · · · · · · · ·A. Well, I'm going to say that

·6· · the director's referral, the director's order,

·7· · and my reports for all -- for all of the

·8· · inspections, including all of the follow-ups,

·9· · pretty much speaks to that.· That was the state

10· · of the home --

11· · · · · · · · · ·Q. Okay.· So you --

12· · · · · · · · · ·A. -- and coupled with the other

13· · things that I said about it's a traumatic

14· · situation that that home was in.· The staff

15· · were traumatized.

16· · · · · · · · · ·MR. SCOTT:· Okay.· Thank you.

17· · · · · · · · · ·Those are my questions.

18· · · · · · · · · ·THE COMMISSIONER:· Thank you,

19· · · · · · · · · ·Mr. Scott.

20· · · · · · · · · ·MS. CORRENTE:· Good morning,

21· · · · · · · · · ·Madam Commissioner.

22· · · · · · · · · ·CROSS-EXAMINATION BY

23· · · · · · · · · ·MS. CORRENTE:

24· · · · · · · · · ·Q. Good morning, Rhonda.· I just

25· · have a few questions for you this morning.

26· · · · · · · · · ·I see from your Affidavit that

27· · you worked in long-term care as a Director of

28· · Care for seven years?

29· · · · · · · · · ·A. Yes.

30· · · · · · · · · ·Q. Is that right?

31· · · · · · · · · ·A. Yes.

32· · · · · · · · · ·Q. Okay.· And I recall in your

Page 6908·1· · testimony yesterday, you said that it was a

·2· · tough position to be a Director of Care; is

·3· · that accurate?

·4· · · · · · · · · ·A. Hard job.

·5· · · · · · · · · ·Q. It's a hard job.· Okay.

·6· · · · · · · · · ·And I take it that it's a hard

·7· · job because a Director of Care has a lot of

·8· · responsibility in managing the nursing staff to

·9· · ensure proper resident care; is that fair to

10· · say?

11· · · · · · · · · ·A. Yes.

12· · · · · · · · · ·Q. And yesterday -- sorry, it

13· · wasn't yesterday because I -- it was the other

14· · day.· Time is flying too quickly.· The other

15· · day, Ms. Simpson --

16· · · · · · · · · ·A. No, it's not going by quick

17· · enough.

18· · · · · · · · · ·Q. Not for you.

19· · · · · · · · · ·The other day, Ms. Simpson

20· · testified that good leadership in a long-term

21· · care home is crucial.· Would you agree with

22· · that?

23· · · · · · · · · ·A. Definitely.

24· · · · · · · · · ·Q. And would you agree that

25· · strong leadership in the home is critical to

26· · leading a home in achieving compliance with the

27· · act; is that fair to say?

28· · · · · · · · · ·A. Definitely.

29· · · · · · · · · ·Q. Why is it that as Ministry

30· · inspectors, you're concerned about the turnover

31· · in leadership at a long-term care home?· You

32· · mentioned a ripple effect on nursing staff.

Page 6909·1· · Could you elaborate on that?

·2· · · · · · · · · ·A. It's been my experience

·3· · personally that the attitude of the staff

·4· · reflects the attitude of the leadership.· And

·5· · there's a reason we have leaders.· It's

·6· · necessary.· I'm not sure how to explain that

·7· · otherwise.

·8· · · · · · · · · ·If staff don't have confidence

·9· · in their leader or there isn't a leader, they

10· · don't feel secure in their -- performing their

11· · duties.· There has to be guidelines for people

12· · to work within, and someone needs to be there

13· · to ensure that it happens.

14· · · · · · · · · ·It's -- it's similar to the

15· · legislation.· All of those guidelines are there

16· · to make sure the residents get their care.· And

17· · that's what we do in Ontario.· We put laws in

18· · place to try to make sure that people follow

19· · them to ensure the care of the residents.

20· · · · · · · · · ·And then when you put a law in

21· · place, you need to have people coming in and

22· · checking to make sure that they're following

23· · it.

24· · · · · · · · · ·Q. So if I can kind of take from

25· · that, is it fair to say, then, that the staff

26· · need to have confidence in their leaders and to

27· · ensure that someone is there to guide them in

28· · order -- and if that's not there, that could

29· · potentially affect the care that's provided to

30· · residents?

31· · · · · · · · · ·A. That was much better said

32· · than what I just said.

Page 6910·1· · · · · · · · · ·Q. Thanks.· Okay.

·2· · · · · · · · · ·Now, you left your position as a

·3· · Director of Care to become a Ministry

·4· · inspector; is that right?

·5· · · · · · · · · ·A. Yes.

·6· · · · · · · · · ·Q. And I understand from

·7· · Ms. Moroney's Affidavit -- and we expect that

·8· · she'll give this testimony later today -- is

·9· · that she was formerly an Assistant Director of

10· · care and a Director Or Care prior to joining

11· · the Ministry as an inspector.· Are you aware of

12· · that?

13· · · · · · · · · ·A. I'll have to trust you on

14· · that one.

15· · · · · · · · · ·Q. Okay.· Well, you know, we can

16· · always ask Ms. Moroney.· Thank you.

17· · · · · · · · · ·In paragraph 6 of your

18· · Affidavit, it says that you -- when you joined

19· · the London SAO in 2013, there were about 16

20· · inspectors there.· Do you recall that?

21· · · · · · · · · ·A. Yes.

22· · · · · · · · · ·Q. And we can bring that up,

23· · although I only have one other question about

24· · it.· It would be paragraph 6 on page 2.

25· · · · · · · · · ·And most of these inspectors

26· · came from management positions within long-term

27· · care; is that fair to say?

28· · · · · · · · · ·A. Generally, yes.

29· · · · · · · · · ·Q. And is it common for most

30· · inspectors at the Ministry to have held

31· · management positions within long-term care?

32· · · · · · · · · ·A. I would say that having

Page 6911·1· · experience in managing in a long-term care home

·2· · provides you with good experience to be able to

·3· · do this job, so it would be an asset for an

·4· · inspector.

·5· · · · · · · · · ·Q. And I understand that, but

·6· · based on your knowledge of where your

·7· · colleagues have come from, is it fair to say,

·8· · to your knowledge, a fair number of them have

·9· · come from positions in long-term care?

10· · · · · · · · · ·A. Some of them, yes.

11· · · · · · · · · ·Q. And I understand that there

12· · was -- what you described, I believe, as a

13· · large wave of inspectors that were hired by the

14· · Ministry in the fall of 2013?

15· · · · · · · · · ·A. Yes.

16· · · · · · · · · ·Q. And I believe that you said

17· · that the inspection staff at the London SAO

18· · doubled at that time?

19· · · · · · · · · ·A. Yes.

20· · · · · · · · · ·Q. Do you know if those newly

21· · hired inspectors mostly or also came from

22· · management positions in long-term care?

23· · · · · · · · · ·A. I wouldn't be able to comment

24· · on that.

25· · · · · · · · · ·Q. You don't know?

26· · · · · · · · · ·A. No.

27· · · · · · · · · ·Q. Okay.· Given that we talked

28· · about senior leaders within a home being

29· · critical to achieving compliance and leading

30· · the nursing staff for the purposes of providing

31· · resident care, does it concern you that the

32· · senior leaders are being hired away from the

Page 6912·1· · homes by the Ministry in what appear to be

·2· · meaningful numbers?

·3· · · · · · · · · ·A. I would have to say no,

·4· · because I'm one of them, and I wanted to go to

·5· · the Ministry.· So I -- I can't -- I can't say

·6· · that.

·7· · · · · · · · · ·Q. No, I understand that you

·8· · wanted to go, but my question to you is does

·9· · it -- let me put a scenario to you.

10· · · · · · · · · ·If we had a scenario, for

11· · instance, where an administrator and a Director

12· · of Care at the same home resigned from their

13· · positions effective the same date because they

14· · were hired as Ministry inspectors, would you be

15· · concerned about that loss of leadership within

16· · a long-term care home?

17· · · · · · · · · ·A. I would be concerned for the

18· · home that they lost all of their managers at

19· · the same time regardless of where they went to

20· · work.

21· · · · · · · · · ·Q. Fair enough.· And given that,

22· · do you not think that such a hiring practice by

23· · an employer, including the Ministry, can place

24· · the home at risk of noncompliance with the act

25· · in view of this loss of leadership at the same

26· · time?

27· · · · · · · · · ·A. That wasn't my decision.

28· · They don't ask my input on those things, and

29· · I'm not in a position to be able to comment on

30· · that.

31· · · · · · · · · ·Q. Do you know if the Ministry

32· · has a policy regarding recruitment of

Page 6913·1· · inspectors from the long-term care sector?

·2· · · · · · · · · ·A. I have no idea.

·3· · · · · · · · · ·Q. Do you know if the Ministry

·4· · gives any thought in its hiring practices to

·5· · the number of managers within a long-term care

·6· · home that it hires, the timing of these hires,

·7· · and how many hires it makes from the same home?

·8· · Do you know if the Ministry gives any thought

·9· · to that?

10· · · · · · · · · ·A. I would not be -- sorry.

11· · · · · · · · · ·MS. STEPHENS:· I'm just going to

12· · · · · · · · · ·rise here because I think she's

13· · · · · · · · · ·already said she actually can't

14· · · · · · · · · ·really speak to any sort of

15· · · · · · · · · ·policy, and this is getting into

16· · · · · · · · · ·the nuts and bolts of what that

17· · · · · · · · · ·policy would be, so I think it's

18· · · · · · · · · ·outside her area.

19· · · · · · · · · ·MS. CORRENTE:· Well, if it's

20· · · · · · · · · ·outside her area, she can simply

21· · · · · · · · · ·state that, and I'll move on.

22· · · · · · · · · ·THE COMMISSIONER:· All right. I

23· · · · · · · · · ·think she has, and she was about

24· · · · · · · · · ·to until we heard the objection.

25· · · · · · · · · ·It does seem like it's outside

26· · · · · · · · · ·her area.

27· · · · · · · · · ·BY MS. CORRENTE:

28· · · · · · · · · ·Q. Do you think that the

29· · Ministry should have a policy regarding the

30· · recruitment of nurse management from long-term

31· · care?

32· · · · · · · · · ·A. I don't know.· I haven't

Page 6914·1· · given that any thought.

·2· · · · · · · · · ·Q. Let's think about it.· Given

·3· · what you've testified to in terms of the effect

·4· · that potential loss of leadership can have on

·5· · the operations of a home and resident care, do

·6· · you think that the Ministry, as an employer,

·7· · should have a policy regarding these recruiting

·8· · practices for long-term care?

·9· · · · · · · · · ·A. I'm going to trust that the

10· · people that make those decisions make them with

11· · their education and their experience in the

12· · guidelines of their roles.· And I don't have an

13· · opinion on that.

14· · · · · · · · · ·Q. Okay.· So can I take it,

15· · then, from your testimony that you're trusting

16· · that those at the Ministry in the position --

17· · with the recruiting role would give thought to

18· · that type of effect on long-term care; is that

19· · fair to say?

20· · · · · · · · · ·MR. KLOEZE:· I understood --

21· · · · · · · · · ·I think this is, again, pushing

22· · · · · · · · · ·a bit too far.· I think that I

23· · · · · · · · · ·understood Ms. Kukoly's answer

24· · · · · · · · · ·as being that she trusted those

25· · · · · · · · · ·people to take whatever relevant

26· · · · · · · · · ·considerations are appropriate.

27· · · · · · · · · ·THE COMMISSIONER:· It's way

28· · · · · · · · · ·outside her --

29· · · · · · · · · ·MS. CORRENTE:· Okay.· I'll move

30· · · · · · · · · ·on.

31· · · · · · · · · ·THE COMMISSIONER:· -- the reason

32· · · · · · · · · ·she's been tendered as a

Page 6915·1· · · · · · · · · ·witness.

·2· · · · · · · · · ·MS. CORRENTE:· Fair enough.

·3· · · · · · · · · ·BY MS. CORRENTE:

·4· · · · · · · · · ·Q. You testified yesterday that

·5· · the inspections branch of the Ministry has a

·6· · list of administrators and Directors of Care in

·7· · each home?

·8· · · · · · · · · ·A. Yes.

·9· · · · · · · · · ·Q. Okay.· So it would be

10· · possible, then, when making hiring decisions

11· · for the Ministry to know where these newly

12· · hired inspectors are coming from in terms of

13· · their role in long-term care?

14· · · · · · · · · ·A. I have no idea.

15· · · · · · · · · ·Q. Well, I just want to be

16· · clear.· You said that the inspections branch

17· · has access to a list; is that fair?

18· · · · · · · · · ·A. A list of the current

19· · administrators.

20· · · · · · · · · ·Q. And Directors of Care?

21· · · · · · · · · ·A. Yes.

22· · · · · · · · · ·Q. Is that limited to the

23· · inspections branch, or does --

24· · · · · · · · · ·A. I have no idea.· I work in

25· · the inspections branch.

26· · · · · · · · · ·Q. Okay.· Fair enough.

27· · · · · · · · · ·Given that you're able to make

28· · suggestions to the inspections branch -- that's

29· · what you testified to?· You're able to make

30· · suggestions?

31· · · · · · · · · ·A. Yes.

32· · · · · · · · · ·Q. Given you're able to make

Page 6916·1· · suggestions and given the growing need for

·2· · long-term care beds, the challenges that homes

·3· · are having hiring nurses and the growing need

·4· · for Ministry inspectors given that you said

·5· · that there's a lack of resources in the London

·6· · SAO, do you feel that it would be important --

·7· · do you feel that it would be a good

·8· · recommendation or a good suggestion to make

·9· · that the Ministry review its hiring practices

10· · in relation to hiring inspectors from the

11· · long-term care sector?

12· · · · · · · · · ·MR. KLOEZE:· Again, this is

13· · · · · · · · · ·going far outside Ms. Kukoly's

14· · · · · · · · · ·understanding and her expertise.

15· · · · · · · · · ·I don't think that's a proper

16· · · · · · · · · ·question.

17· · · · · · · · · ·MS. CORRENTE:· Well, I don't

18· · · · · · · · · ·know that it is.· I mean, she's

19· · · · · · · · · ·testified that she's worked in

20· · · · · · · · · ·long-term care.· She was a

21· · · · · · · · · ·Director of Care in a management

22· · · · · · · · · ·position.

23· · · · · · · · · · · She's testified that she

24· · · · · · · · · ·is -- that she has an opinion as

25· · · · · · · · · ·to the effects of loss of

26· · · · · · · · · ·leadership in the home.· And

27· · · · · · · · · ·she's testified that she's able

28· · · · · · · · · ·to make suggestions.

29· · · · · · · · · · · And what I'm asking her is if

30· · · · · · · · · ·she thinks that would be a

31· · · · · · · · · ·worthwhile suggestion to make.

32· · · · · · · · · ·MR. KLOEZE:· I understood

Page 6917·1· · · · · · · · · ·Ms. Kukoly's evidence as to

·2· · · · · · · · · ·the -- sort of the scope of her

·3· · · · · · · · · ·suggestions would be within her

·4· · · · · · · · · ·office and in the inspections

·5· · · · · · · · · ·branch, not about hiring

·6· · · · · · · · · ·practices in general.

·7· · · · · · · · · ·MS. CORRENTE:· Well, I'm

·8· · · · · · · · · ·suggesting that she can make

·9· · · · · · · · · ·that suggestion within the scope

10· · · · · · · · · ·of her office.

11· · · · · · · · · ·THE COMMISSIONER:· I'm going to

12· · · · · · · · · ·ask you to move on.· I think

13· · · · · · · · · ·that it's quite clear that this

14· · · · · · · · · ·whole line of questioning is

15· · · · · · · · · ·outside her area of expertise.

16· · · · · · · · · · · She doesn't do the hiring.

17· · · · · · · · · ·She doesn't know the hiring.

18· · · · · · · · · ·She doesn't know the policies.

19· · · · · · · · · ·MS. CORRENTE:· Okay.· Then I

20· · · · · · · · · ·will have in further questions.

21· · · · · · · · · ·Thank you.

22· · · · · · · · · ·THE COMMISSIONER:· Thank you,

23· · · · · · · · · ·Ms. Corrente.

24· · · · · · · · · ·MS. STEPHENS:· Commissioner, I'm

25· · · · · · · · · ·cognizant that it is 11 o'clock.

26· · · · · · · · · ·Mr. Golden will be next up. I

27· · · · · · · · · ·don't anticipate he will

28· · · · · · · · · ·complete his cross-examination

29· · · · · · · · · ·in 15 minutes, although I would

30· · · · · · · · · ·encourage that, so perhaps it

31· · · · · · · · · ·would make sense to take our

32· · · · · · · · · ·break now, and then we could

Page 6918·1· · · · · · · · · ·begin cross-examination after

·2· · · · · · · · · ·the morning break.

·3· · · · · · · · · ·THE COMMISSIONER:· Is that

·4· · · · · · · · · ·agreeable to you, Mr. Golden?

·5· · · · · · · · · ·MR. GOLDEN:· That's fine.

·6· · · · · · · · · ·THE COMMISSIONER:· Thank you.

·7· · · · · · · · · ·We'll take the morning recess.

·8· · · · · · · · · ·THE REGISTRAR:· This Public

·9· · · · · · · · · ·Inquiry is on recess for 15

10· · · · · · · · · ·minutes.

11· · · · · · · · · ·-- RECESSED AT 11:04 A.M.

12· · · · · · · · · ·-- RESUMED AT 11:21 A.M.

13· · · · · · · · · ·THE COMMISSIONER:· Mr. Golden.

14· · · · · · · · · ·CROSS-EXAMINATION BY MR. GOLDEN:

15· · · · · · · · · ·Q. Thank you.· So my name is

16· · David Golden.· I am counsel for Caressant Care,

17· · and I also have some questions for you.

18· · · · · · · · · ·Now, I understood that you have

19· · been an Inspector since I think it was April of

20· · 2013; is that right?

21· · · · · · · · · ·A. Yes.

22· · · · · · · · · ·Q. And the other Inspector who

23· · was primarily with you at Caressant Care

24· · Woodstock, who was that?

25· · · · · · · · · ·A. Marian MacDonald.

26· · · · · · · · · ·Q. And I understand that she

27· · became an Inspector in 2014?

28· · · · · · · · · ·A. No.

29· · · · · · · · · ·Q. When did she become an

30· · Inspector?

31· · · · · · · · · ·A. I don't know, but she was

32· · there when I got there.

Page 6919·1· · · · · · · · · ·Q. Okay, fine.· And on Tuesday

·2· · Karen Simpson was taken to a number of

·3· · regulations under the Long-Term Care Homes Act,

·4· · and we don't need to go there, that set out

·5· · various requirements for qualifications for

·6· · both Administrators and Directors of Care in

·7· · long-term care.

·8· · · · · · · · · ·And I am wondering, are you

·9· · aware of any similar regulatory requirements

10· · for qualifications for Inspectors?

11· · · · · · · · · ·A. I don't know.

12· · · · · · · · · ·Q. Okay.· And you have already

13· · been asked about the training that you had for

14· · interviews, and you mentioned police training.

15· · Was that a day, a half day, a seminar?· What do

16· · you remember about that?

17· · · · · · · · · ·A. It was part of a two-day

18· · workshop for Inspectors where we had a lot of

19· · education about a lot of things, and that was

20· · part of it.· To tell you exactly how long it

21· · was, I could only guess.

22· · · · · · · · · ·Q. That is fine.· I don't want

23· · you to guess.· It was part of a two-day

24· · workshop where you were covering a lot of

25· · topics?

26· · · · · · · · · ·A. Correct.

27· · · · · · · · · ·Q. All right.· And I gather that

28· · there has been a lot of preparation on your

29· · side to make sure that you would come here and

30· · give careful and accurate testimony here at the

31· · Inquiry?

32· · · · · · · · · ·A. Can you say that again?

Page 6920·1· · · · · · · · · ·Q. Yes, I gather there has been

·2· · a lot of time invested by you in preparing to

·3· · come here to give evidence at the Inquiry?

·4· · · · · · · · · ·A. Yes.· I want to come prepared

·5· · for everything I do.

·6· · · · · · · · · ·Q. For sure.· And so you have

·7· · watched most of the testimony so far?

·8· · · · · · · · · ·A. Some of it.

·9· · · · · · · · · ·Q. And you had reviewed I assume

10· · a number of times your affidavit before it was

11· · finalized?

12· · · · · · · · · ·A. What would you say is a

13· · number of times?

14· · · · · · · · · ·Q. The affidavit that is in

15· · front of you that was sworn and introduced into

16· · evidence, is that the first draft that you

17· · reviewed of the affidavit?

18· · · · · · · · · ·A. No.

19· · · · · · · · · ·Q. No.· It went through I would

20· · suggest a number of drafts before it was

21· · finalized?

22· · · · · · · · · ·A. More than one.

23· · · · · · · · · ·Q. Okay.· And you would have

24· · also reviewed Karen Simpson's affidavit?

25· · · · · · · · · ·A. No.

26· · · · · · · · · ·Q. Before giving your evidence?

27· · · · · · · · · ·A. No.

28· · · · · · · · · ·Q. You had never read it before

29· · coming and giving evidence yesterday?

30· · · · · · · · · ·A. No.

31· · · · · · · · · ·Q. Okay.· And the underlying

32· · documents that you inspected, did you have a

Page 6921·1· · chance to review those before you -- that

·2· · formed -- that were part of your report, did

·3· · you review those documents before coming here?

·4· · · · · · · · · ·A. That were part of my -- what,

·5· · I'm sorry?

·6· · · · · · · · · ·Q. The documents that you

·7· · reviewed as the basis for your Inspection

·8· · Reports, did you review those documents?

·9· · · · · · · · · ·A. All of them?· No.

10· · · · · · · · · ·Q. Which ones did you review, in

11· · categories?· I don't want you to explain every

12· · single one.

13· · · · · · · · · ·A. I read through some of the

14· · interviews.

15· · · · · · · · · ·Q. Okay.

16· · · · · · · · · ·A. I looked at the Medication IP

17· · at Meadow Park London.· I reviewed the reports.

18· · I looked at some of the judgment matrix

19· · decision-making tools.· I can't think of what

20· · else I reviewed.

21· · · · · · · · · ·Q. That is fine.· And you were

22· · here when Ms. Simpson was giving her evidence?

23· · · · · · · · · ·A. Yes.

24· · · · · · · · · ·Q. And were there any other

25· · witnesses that you were here when they were

26· · giving their evidence, who have given evidence

27· · at the Inquiry?

28· · · · · · · · · ·A. I was here for -- I am not

29· · sure if I was here for all of them, but I was

30· · here for Helen Crombez - and I don't know if it

31· · was some or all, but definitely some - Brenda

32· · Van Quaethem, Karen Routledge, Laura Long,

Page 6922·1· · Dr. Reddick, Joanne Polkiewicz.· I am drawing a

·2· · blank as to who else there was.

·3· · · · · · · · · ·Q. That is fine.· Did you find

·4· · that it was helpful in preparing you to give

·5· · your evidence to have heard their evidence?

·6· · · · · · · · · ·A. It was helpful to go back

·7· · hearing some of the evidence just to refresh my

·8· · memory, because it was two years ago and I can

·9· · tell you there was a massive amount of

10· · information that we collected.· So it was a

11· · good refresher for my memory.

12· · · · · · · · · ·Q. And I'm curious about that

13· · because I gathered from what you explained to

14· · Commission Counsel yesterday, when you

15· · interviewed the staff at Caressant Care in the

16· · fall of 2016, they weren't given an opportunity

17· · to prepare for those interviews by reviewing

18· · documentation and getting a heads-up on what

19· · the specific incidents they would be questioned

20· · about, were they?

21· · · · · · · · · ·A. I don't think so.

22· · · · · · · · · ·Q. And having now gone through

23· · the process and you have said it was two years

24· · ago, you would agree with me that the staff who

25· · you were interviewing at Caressant Care

26· · Woodstock were being asked about incidents that

27· · happened as long as nine years before you sat

28· · down with them for an interview?

29· · · · · · · · · ·A. That is definitely fair to

30· · say.

31· · · · · · · · · ·Q. And I think understood from

32· · what you said yesterday to counsel that with

Page 6923·1· · respect to the Meadow Park IP, which you

·2· · conducted in November of 2014, and you were

·3· · there on a focussed inspection, you had no

·4· · actual recollection of the details of what you

·5· · did and you had to --

·6· · · · · · · · · ·A. Some, but not to great

·7· · detail, no.

·8· · · · · · · · · ·Q. Your evidence was based on

·9· · going back and reading and thinking about what

10· · had happened there; correct?

11· · · · · · · · · ·A. Right.

12· · · · · · · · · ·Q. So if that was your situation

13· · and your memory being an Inspector of an event

14· · that was -- that happened in November of 2014,

15· · how would you expect someone like Helen Crombez

16· · going through what you have described in the

17· · fall of 2016 to remember events that happened

18· · not a month before or two months or two years,

19· · but nine years before?

20· · · · · · · · · ·A. It would be difficult.

21· · · · · · · · · ·Q. And I understand from the

22· · process that you have described that the

23· · interviews with the staff at Caressant Care

24· · were taped?

25· · · · · · · · · ·A. They were audio recorded.

26· · · · · · · · · ·Q. Audio recorded, okay.· And

27· · how quickly were transcripts prepared of the

28· · audio recordings, or were transcripts prepared

29· · of the audio recordings?

30· · · · · · · · · ·A. So what happened during the

31· · interviews was Marian would ask the questions

32· · and I would type.· We had most of the questions

Page 6924·1· · pre-prepared, but depending on what someone

·2· · says, occasionally you think of a new question

·3· · in the middle of it.

·4· · · · · · · · · ·So I did my best to type what

·5· · was being said during the interview, and then I

·6· · would go back later and do my best to fill in

·7· · the blanks that I had missed, because I can't

·8· · type that fast.

·9· · · · · · · · · ·But it wasn't -- I -- there is

10· · no way it is verbatim, and they weren't

11· · transcribed by like someone who does it

12· · professionally and it wasn't electronic

13· · transcription or anything like that.· It was

14· · just me listening to it and trying to fill in

15· · the blanks.

16· · · · · · · · · ·Q. All right, and then after you

17· · would listen to it and fill in the blanks, you

18· · would end up with a typed record of what the

19· · interview was?

20· · · · · · · · · ·A. Yes.

21· · · · · · · · · ·Q. All right.· And at any time

22· · did you share those typed interview notes with

23· · the interviewees?

24· · · · · · · · · ·A. No.

25· · · · · · · · · ·Q. And did you ever tell them or

26· · offer to them an opportunity to review the

27· · typed notes so that they could reflect on

28· · whether they were complete or accurate?

29· · · · · · · · · ·A. No.

30· · · · · · · · · ·Q. And did you ever offer to

31· · provide the audio recordings to the

32· · interviewees?

Page 6925·1· · · · · · · · · ·A. No.

·2· · · · · · · · · ·Q. And were the interviewees

·3· · allowed to have someone sit in with them during

·4· · the interviews?

·5· · · · · · · · · ·A. No one asked.

·6· · · · · · · · · ·Q. Okay.· And I understand and

·7· · we heard some evidence from Karen Simpson the

·8· · other day that under the current inspection

·9· · regime, the practice is not to allow

10· · interviewees who want to have counsel, not to

11· · allow them to have counsel present during

12· · interviews.· Is that your understanding as

13· · well?

14· · · · · · · · · ·A. It is my understanding that

15· · that has been a recent change.

16· · · · · · · · · ·Q. All right.· And how have you

17· · been trained on what to say if a staff member,

18· · or any person, because you can interview any

19· · person, says, Hey, I want to have my legal

20· · counsel present?· What are you trained to say

21· · as to why they can't?

22· · · · · · · · · ·A. It is in the legislation.

23· · · · · · · · · ·Q. That is the full extent of

24· · it, of your training and the explanation, is it

25· · is in the legislation and, therefore, you can't

26· · have a legal counsel present?

27· · · · · · · · · ·A. I don't have any other answer

28· · than that.

29· · · · · · · · · ·Q. So has there been any

30· · internal kind of seminar or bulletin on what to

31· · do if someone wants legal counsel?

32· · · · · · · · · ·MS. STEPHENS:· I am just going

Page 6926·1· · · · · · · · · ·to rise here.· Mr. Golden can

·2· · · · · · · · · ·use his time as he wishes, but I

·3· · · · · · · · · ·would note we are trying to

·4· · · · · · · · · ·complete a number of witnesses

·5· · · · · · · · · ·today and tomorrow, and this is

·6· · · · · · · · · ·an area of legislation that has

·7· · · · · · · · · ·just come into effect.· It was

·8· · · · · · · · · ·not in time at the -- it was not

·9· · · · · · · · · ·in place at the time of the

10· · · · · · · · · ·inspections, so I think we are

11· · · · · · · · · ·entering into a territory that

12· · · · · · · · · ·doesn't have much relevance to

13· · · · · · · · · ·this part of the Inquiry.

14· · · · · · · · · ·MR. GOLDEN:· Well, you know,

15· · · · · · · · · ·with all due respect, a

16· · · · · · · · · ·substantial amount of time was

17· · · · · · · · · ·devoted to events at Caressant

18· · · · · · · · · ·Care which post-date Elizabeth

19· · · · · · · · · ·Wettlaufer's employment there,

20· · · · · · · · · ·going right through to the end

21· · · · · · · · · ·of 2017, and there was a

22· · · · · · · · · ·tremendous amount of time in

23· · · · · · · · · ·affidavits and in evidence that

24· · · · · · · · · ·has been devoted to changes in

25· · · · · · · · · ·the system, including changes

26· · · · · · · · · ·which happened after, you know,

27· · · · · · · · · ·2014.· And this was an area that

28· · · · · · · · · ·was covered by Karen Simpson.

29· · · · · · · · · ·I think --

30· · · · · · · · · ·THE COURT:· Go ahead.· You can

31· · · · · · · · · ·use your time as you wish, and I

32· · · · · · · · · ·don't see a reason to preclude

Page 6927·1· · · · · · · · · ·you from this line.

·2· · · · · · · · · ·BY MR. GOLDEN:

·3· · · · · · · · · ·Q. Thank you.

·4· · · · · · · · · ·So just I want to understand

·5· · that in terms of this change now, if an

·6· · interviewee says to you, I'm feeling kind of

·7· · intimidated by this process and I would like to

·8· · have counsel there, your training is to respond

·9· · that the legislation doesn't allow it, and that

10· · is the full extent of what you understand you

11· · should be explaining?

12· · · · · · · · · ·A. Obviously, I am going to try

13· · to make that staff member feel comfortable.· We

14· · have a staff interview list that we fill out to

15· · keep a record of the people that we have

16· · interviewed, and on the back of that is the

17· · legislation related to whistle-blowing

18· · protection.

19· · · · · · · · · ·So I might ask the staff member

20· · the reason for their hesitance, and if they

21· · feel that whistle-blowing protection is an

22· · issue for them and that is why their

23· · hesitation, and then I might refer them to that

24· · legislation and assure them that if they ever

25· · felt that there was retaliation, that we would

26· · encourage them to let the Ministry know and we

27· · would follow up on that because, as Karen

28· · Simpson said, the Ministry takes that very

29· · seriously.

30· · · · · · · · · ·So as a human being and a nurse,

31· · no, I would not just say that is the

32· · legislation.· I was under the impression that

Page 6928·1· · you asked me the reason that I had for that,

·2· · and that is all I have.

·3· · · · · · · · · ·Q. And I wasn't really talking

·4· · about intimidation of the interviewee by an

·5· · outsider.· I was talking about them feeling

·6· · intimidated by the substantial powers that the

·7· · Ministry has as a result of an investigation.

·8· · That is what I was referring to, so that we are

·9· · clear.

10· · · · · · · · · ·MR. KLOEZE:· Commissioner, I

11· · · · · · · · · ·would just caution that the

12· · · · · · · · · ·language that Mr. Golden is

13· · · · · · · · · ·using in terms of

14· · · · · · · · · ·"investigation" is certainly not

15· · · · · · · · · ·the language that Ms. Kukoly

16· · · · · · · · · ·uses.· Perhaps he can clarify

17· · · · · · · · · ·that.

18· · · · · · · · · ·BY MR. GOLDEN:

19· · · · · · · · · ·Q. Okay, sure, let's refer it

20· · back to something that Karen Simpson said on

21· · Tuesday, and she said, you know, an interview

22· · can turn into an investigation if there is

23· · possible charges, and then perhaps legal

24· · counsel might be appropriate at that point.

25· · · · · · · · · ·Do you have any training on when

26· · an interview might become an investigation

27· · because possible charges could arise?

28· · · · · · · · · ·A. Not yet.

29· · · · · · · · · ·Q. Okay.· Now, I understood from

30· · your affidavit that the actual first day that

31· · you started the investigation at Caressant Care

32· · with interviews --

Page 6929·1· · · · · · · · · ·A. Inspection.

·2· · · · · · · · · ·Q. Sorry, inspection, yes, and

·3· · interview of witnesses was the actual day that

·4· · the police charges were announced in Woodstock

·5· · and there was a press conference; was that your

·6· · recollection?

·7· · · · · · · · · ·A. The inspection was officially

·8· · started on October 5th.

·9· · · · · · · · · ·Q. Yes, but I am talking about

10· · in the home.

11· · · · · · · · · ·A. Well, we went to the home on

12· · October 5th.

13· · · · · · · · · ·Q. Okay, if we look at your

14· · affidavit and just quickly turn to tab

15· · number -- or paragraph number 93.

16· · · · · · · · · ·A. I can see where you are

17· · coming from now.

18· · · · · · · · · ·Q. Okay, in paragraph 93 you say

19· · that you and Marian MacDonald:

20· · · · · · · · · ·"[...] went to [Caressant Care

21· · · · · · · · · ·Woodstock] to begin [y]our

22· · · · · · · · · ·on-site inspection on the

23· · · · · · · · · ·afternoon of the day that police

24· · · · · · · · · ·held their news conference

25· · · · · · · · · ·announcing criminal charges

26· · · · · · · · · ·against [Elizabeth Wettlaufer]."

27· · · · · · · · · ·And I am wondering whether in

28· · choosing that particular day, did you consider

29· · the impact on the staff of having the Ministry

30· · show up to do an inspection, their on-site

31· · inspection on the very day that this became a

32· · huge media story in Woodstock?

Page 6930·1· · · · · · · · · ·A. I didn't choose the day.

·2· · · · · · · · · ·Q. Okay.· And I think you have

·3· · been really candid and open about your

·4· · observations regarding the trauma that the home

·5· · was under and that the staff were under, and I

·6· · appreciate that.

·7· · · · · · · · · ·And I am wondering whether,

·8· · under those circumstances, are you aware of any

·9· · supports, extra supports that were offered by

10· · the Ministry to assist the home through that

11· · very challenging time period?

12· · · · · · · · · ·A. I am not aware, but I did ask

13· · the home about that during my inspection.

14· · · · · · · · · ·Q. Okay.

15· · · · · · · · · ·A. And it is documented in my

16· · IPs.

17· · · · · · · · · ·Q. And I gather that from

18· · everything you have told us about the focus and

19· · intent of doing inspections, residents come

20· · first; is that fair?

21· · · · · · · · · ·A. Yes.

22· · · · · · · · · ·Q. And so in doing your

23· · inspections in the fall of 2016, did you

24· · interview a number of residents about what

25· · was -- what had happened?

26· · · · · · · · · ·A. About?

27· · · · · · · · · ·Q. Caressant Care Woodstock. I

28· · mean, I know, for example, if you are doing an

29· · RQI, under certain circumstances you might go

30· · in and interview up to 40 people, so I am

31· · wondering how many residents did you interview

32· · as a result of being sent in to do the

Page 6931·1· · Wettlaufer investigation?

·2· · · · · · · · · ·A. I couldn't give you a number.

·3· · I have a resident list of people we

·4· · interviewed.

·5· · · · · · · · · ·Q. Okay.· And would you say, is

·6· · it fair to say that notwithstanding that those

·7· · interviews were conducted right when the story

·8· · broke and the intensity of the media focus, the

·9· · majority of residents you interviewed were

10· · actually supportive of the staff in the home?

11· · · · · · · · · ·A. Very much.

12· · · · · · · · · ·Q. And they in fact were

13· · supportive of the level of care that they felt

14· · they were receiving in the home?

15· · · · · · · · · ·A. Yes.

16· · · · · · · · · ·Q. And that there was no, that

17· · you noticed, there was no attempt for a mass

18· · exodus from the home, people clamouring to find

19· · other accommodation?

20· · · · · · · · · ·A. A mass exodus, no.· There

21· · were a couple that we heard that had concerns,

22· · and that would be understandable to me.

23· · · · · · · · · ·Q. And you met with the

24· · Residents' Council as well?

25· · · · · · · · · ·A. Yes.

26· · · · · · · · · ·Q. And is it fair to say that

27· · the Residents' Council were supportive of the

28· · home?

29· · · · · · · · · ·A. Yes.

30· · · · · · · · · ·Q. And was it fair to say that

31· · the Residents' Council wasn't expressing to you

32· · serious concerns about the quality of care,

Page 6932·1· · never mind and I am not talking about

·2· · compliance with regs, but the actual hands-on

·3· · care?· There was not a lot of concern expressed

·4· · about that?

·5· · · · · · · · · ·A. That is my recollection.

·6· · · · · · · · · ·Q. And I think you said that as

·7· · part of your exercise, you reviewed minutes

·8· · from the Residents' Council?

·9· · · · · · · · · ·A. I believe so, yes.

10· · · · · · · · · ·Q. And would you have

11· · interviewed the president of the Residents'

12· · Council more than once, like over the course of

13· · months that you were there?

14· · · · · · · · · ·A. I don't think so.· I don't

15· · think so, but I remember talking to them

16· · about -- because we did so many different

17· · inspections concurrently, I did talk to that

18· · resident more than once.

19· · · · · · · · · ·Q. And did that president of the

20· · Residents' Council share with you any

21· · information about any support that was offered

22· · to the Residents' Council from outside groups

23· · such as the OARC?· Do you remember anything

24· · about that?

25· · · · · · · · · ·A. I don't remember.

26· · · · · · · · · ·Q. Okay.· Now, we had some

27· · discussions with Ms. Simpson specifically about

28· · section 24 and the obligation to report, and

29· · there is a document that is in the brief that

30· · Mr. Van Kralingen had given you.

31· · · · · · · · · ·A. Oh, I put that away.

32· · · · · · · · · ·Q. It is at tab number 6 of that

Page 6933·1· · brief, and it is document number 55639.

·2· · · · · · · · · ·A. Yes.

·3· · · · · · · · · ·Q. I take it you have seen this

·4· · document before?

·5· · · · · · · · · ·A. I believe I did see it. I

·6· · believe it was emailed to Inspectors.

·7· · · · · · · · · ·Q. Okay, and it is dated

·8· · February 12th, 2015, and it is called "Re:

·9· · Clarification of Mandatory and Critical

10· · Incident Reporting Requirements"; do you see

11· · that?

12· · · · · · · · · ·A. That is what it says.

13· · · · · · · · · ·Q. Now, is it your understanding

14· · that the Director at the Ministry sends a --

15· · will consider sending a blanket memo to the

16· · whole long-term care sector if there is a

17· · perception that there is a particular issue is

18· · not well understood?

19· · · · · · · · · ·A. I can't speak to the

20· · decision-making of the Director.

21· · · · · · · · · ·Q. All right.· And do you have

22· · any understanding as to whether this particular

23· · memo "Re:· Clarification of Mandatory and

24· · Critical Incident Reporting" was sent to homes

25· · and as well to you, I understand, in order to

26· · provide some clarity over reporting?

27· · · · · · · · · ·MR. KLOEZE:· Commissioner, I

28· · · · · · · · · ·think that Mr. Golden is asking

29· · · · · · · · · ·this witness what the intention

30· · · · · · · · · ·of the Director is.· This

31· · · · · · · · · ·witness has said that she may

32· · · · · · · · · ·have received this by email, but

Page 6934·1· · · · · · · · · ·she is not the Director of the

·2· · · · · · · · · ·Inspections Branch.

·3· · · · · · · · · ·THE COMMISSIONER:· Would you

·4· · · · · · · · · ·have any objection if he asks

·5· · · · · · · · · ·this witness what she understood

·6· · · · · · · · · ·from this document, what was the

·7· · · · · · · · · ·intention of the document?

·8· · · · · · · · · ·MR. KLOEZE:· What she

·9· · · · · · · · · ·understood -- well, if she

10· · · · · · · · · ·understood, yes, of what the

11· · · · · · · · · ·intention was of sending this

12· · · · · · · · · ·document, but --

13· · · · · · · · · ·THE COMMISSIONER:· What her

14· · · · · · · · · ·understanding is.

15· · · · · · · · · ·MR. KLOEZE:· What her

16· · · · · · · · · ·understanding of that was, yes.

17· · · · · · · · · ·BY MR. GOLDEN:

18· · · · · · · · · ·Q. Could you tell us your

19· · understanding?

20· · · · · · · · · ·A. I can't say what my

21· · understanding of the intent from the Director

22· · was, but it seems that the title of it is

23· · "Clarification of Mandatory and Critical

24· · Incident Reporting Requirements", so I would

25· · say that that is what it is about.

26· · · · · · · · · ·Q. Okay, and if you look towards

27· · the bottom of the page, it says in bold:

28· · · · · · · · · ·"Subsection 24(1) - 'Reporting

29· · · · · · · · · ·certain matters to the

30· · · · · · · · · ·Director'."

31· · · · · · · · · ·Do you see that?

32· · · · · · · · · ·A. I do.

Page 6935·1· · · · · · · · · ·Q. And then it says underneath:

·2· · · · · · · · · ·"A person who has reasonable

·3· · · · · · · · · ·grounds to suspect that any of

·4· · · · · · · · · ·the following has occurred or

·5· · · · · · · · · ·may occur shall immediately

·6· · · · · · · · · ·report [...]"

·7· · · · · · · · · ·Do you see that?

·8· · · · · · · · · ·A. I do.

·9· · · · · · · · · ·Q. Now, the document is about

10· · five pages long, and you'll have to take my

11· · word for it that nowhere in the five

12· · single-spaced pages is there any discussion

13· · regarding what "reasonable grounds" mean.

14· · · · · · · · · ·And I'm wondering whether you

15· · had any particular training when this went out

16· · or otherwise as to what "reasonable grounds"

17· · actually means from an inspection point of view

18· · and from a home point of view?

19· · · · · · · · · ·A. So there was about six parts

20· · of that question.

21· · · · · · · · · ·Q. Okay.

22· · · · · · · · · ·A. Can you give them to me one

23· · at a time?

24· · · · · · · · · ·Q. Sure.· In addition to

25· · receiving this memo, did you receive anything

26· · that actually explains what is expected in

27· · terms of "reasonable grounds"?

28· · · · · · · · · ·A. No.

29· · · · · · · · · ·Q. All right, then I guess we'll

30· · leave it at that.

31· · · · · · · · · ·Can you go over to tab number

32· · "G" of your affidavit.· That is the Inspection

Page 6936·1· · Plan document 43371.

·2· · · · · · · · · ·A. You said letter "G"?

·3· · · · · · · · · ·Q. Yes, this is tab "G" from

·4· · your affidavit.

·5· · · · · · · · · ·A. Okay.

·6· · · · · · · · · ·Q. 43371.· Okay, you prepared

·7· · this Inspection Plan, Rhonda?

·8· · · · · · · · · ·A. Yes.

·9· · · · · · · · · ·Q. All right, and I take it that

10· · it would have been reviewed prior to you

11· · finalizing it, or would it?

12· · · · · · · · · ·A. Yes, so what happened was

13· · when we were waiting for the okay to go in to

14· · do the inspection, we started working on our

15· · plan, and I literally took a stab at it.· And I

16· · have no experience in inspecting related to

17· · multiple murders, so based on my experience,

18· · this is my best educated guess at what I would

19· · do.

20· · · · · · · · · ·And yes, it got reviewed by

21· · managers and senior managers.

22· · · · · · · · · ·Q. And would this have been --

23· · so that would this have been approved by your

24· · manager, the Inspection Plan?

25· · · · · · · · · ·A. I am going to say no because

26· · there is another one.

27· · · · · · · · · ·Q. Okay, and which is the other

28· · one?

29· · · · · · · · · ·A. Behind the blue slip.

30· · · · · · · · · ·Q. Okay.

31· · · · · · · · · ·A. It is document number 43510.

32· · · · · · · · · ·Q. That is called "off-site ",

Page 6937·1· · right?

·2· · · · · · · · · ·A. Yes, because we do our prep

·3· · off-site.

·4· · · · · · · · · ·Q. Okay.· And I don't see

·5· · anything in the one you have referred to, the

·6· · off-site, that actually deals with the

·7· · questions that you are going to be asking of

·8· · the interviewees, but this first document, the

·9· · Inspection Plan, does say a lot about what you

10· · are going to ask?

11· · · · · · · · · ·A. Because that was me taking a

12· · stab at the Inspection Plan and just thinking

13· · about -- because that is what we normally do,

14· · is think about who we want to talk to and give

15· · some thought as to what questions we might ask.

16· · · · · · · · · ·But the questions were developed

17· · after we were in the home.

18· · · · · · · · · ·Q. Okay.

19· · · · · · · · · ·A. And you can see them

20· · documented in the documented interviews.· So it

21· · wasn't in my plan.

22· · · · · · · · · ·Q. All right.· So I didn't see

23· · anything in your plan that considered the

24· · unique circumstances of how to approach and

25· · interview persons who are undergoing a trauma

26· · of having just been -- having it just been

27· · announced that they were working in a facility

28· · where murders had occurred.· Where did that

29· · come into your plan?

30· · · · · · · · · ·A. Not every single thing I do

31· · is documented in the plan.

32· · · · · · · · · ·Q. Okay.

Page 6938·1· · · · · · · · · ·A. I also say "please" and

·2· · "thank you" to people, and I also ask them when

·3· · they might have time to talk to me, and that is

·4· · not in the plan.

·5· · · · · · · · · ·And I am a Registered Nurse. I

·6· · do have some experience about how to speak to

·7· · people who are distressed, and just because it

·8· · is not documented in my plan doesn't mean I

·9· · can't figure things out along the way based on

10· · my experience and my education and being a

11· · generally kind human being as I go.

12· · · · · · · · · ·Q. Let me ask you this.· Did you

13· · get any expert advice on how to handle

14· · interviewing persons who were in this level of

15· · shock?

16· · · · · · · · · ·A. No.

17· · · · · · · · · ·Q. And did you get any advice

18· · regarding how persons who had just experienced

19· · this kind of traumatic news, how that might

20· · affect their judgment and their memory?

21· · · · · · · · · ·A. No.

22· · · · · · · · · ·Q. If you turn over to page 3 of

23· · this document, there is a list of proposed

24· · questions for the Administrator.· We have to go

25· · another page.· No, I guess, sorry, I think you

26· · had it.· Go back, sorry.

27· · · · · · · · · ·Page 3, "All Administrators

28· · [...]"; do you see that?· And you have got a

29· · list of questions to ask Administrators?

30· · · · · · · · · ·A. I'm sorry, I'm not on the

31· · same page.

32· · · · · · · · · ·Q. It is numbered page 3 of your

Page 6939·1· · exhibit at tab "G".

·2· · · · · · · · · ·A. And is it 43510?

·3· · · · · · · · · ·Q. 43371, the first, the one

·4· · that has --

·5· · · · · · · · · ·A. That wasn't the approved

·6· · plan, though.

·7· · · · · · · · · ·Q. I know, but you have included

·8· · this in your affidavit as an Inspection Plan

·9· · that you drafted, and I want to ask you some

10· · questions about it, if that is okay.

11· · · · · · · · · ·A. Yeah, you get to decide that.

12· · · · · · · · · ·Q. So I just want to know when

13· · you prepared this, did you know who the

14· · Administrator had been over the periods of time

15· · when Ms. Wettlaufer had worked at the facility?

16· · · · · · · · · ·A. I was aware of Brenda Van

17· · Quaethem.

18· · · · · · · · · ·Q. And were you aware of the

19· · fact that Brenda was not a nurse?

20· · · · · · · · · ·A. No.

21· · · · · · · · · ·Q. And you indicate in the

22· · questions for the Administrator, as an example:

23· · · · · · · · · ·"Did you work with or following

24· · · · · · · · · ·RN Elizabeth Wettlaufer?"

25· · · · · · · · · ·Would an Administrator ever be

26· · working following Elizabeth Wettlaufer?

27· · · · · · · · · ·A. Again, this was me just

28· · taking a stab at it.· Like I -- I didn't ask

29· · that question.· This was me just taking a guess

30· · at how to do this inspection, and I documented

31· · it and it is not the one that we used.

32· · · · · · · · · ·So does that make sense?· No.

Page 6940·1· · But did I know what I was doing at that time

·2· · related to that?· I was taking my best educated

·3· · guess about questions to ask, and I don't know

·4· · what else to tell you.

·5· · · · · · · · · ·Q. Okay, I understand that, you

·6· · know --

·7· · · · · · · · · ·A. It didn't impact my

·8· · inspection.

·9· · · · · · · · · ·Q. Okay, we have been given

10· · thousands of pages of documents from the

11· · Ministry.· Is there a revised document that has

12· · your more thoughtful list of questions that you

13· · were going to ask these witnesses?

14· · · · · · · · · ·A. It is in each and every

15· · documented interview.

16· · · · · · · · · ·Q. But is there a template that

17· · you prepared with questions other than this one

18· · that sets out the nature of the questions that

19· · you were going to ask?· I haven't seen it in

20· · the documents.

21· · · · · · · · · ·A. Because we used the template

22· · of the questions to document the answers.

23· · · · · · · · · ·Q. And has there been a template

24· · produced in the course of the Inquiry to show

25· · what your pre-written questions were?

26· · · · · · · · · ·A. It is in the documented

27· · interviews.

28· · · · · · · · · ·Q. So we would have to actually

29· · read the interviews to determine what it is the

30· · questions that you had decided should be asked;

31· · is that fair?

32· · · · · · · · · ·A. Yes.

Page 6941·1· · · · · · · · · ·Q. All right.

·2· · · · · · · · · ·A. But we could have asked more

·3· · questions than were initially on the template

·4· · in the middle of the inspection, in the

·5· · interview, based on an answer, because just

·6· · like you do when you are asking me questions,

·7· · if I say something that makes you go, Hmm, I

·8· · want to know more about that, then you would

·9· · add that question that you hadn't planned to

10· · ask in the first place.

11· · · · · · · · · ·Q. Could we go to page 6 of this

12· · document, please.· And these were your initial

13· · questions that you had in your first run for

14· · physicians; is that right?

15· · · · · · · · · ·A. Yes.

16· · · · · · · · · ·Q. And you were going to be

17· · asking the physicians whether they were on

18· · shift or involved with the residents' care when

19· · they had a change in condition?

20· · · · · · · · · ·MR. KLOEZE:· I think Mr. Golden

21· · · · · · · · · ·is mischaracterizing again sort

22· · · · · · · · · ·of the purpose of this document.

23· · · · · · · · · · · I don't think Ms. Kukoly said

24· · · · · · · · · ·she was going to be asking the

25· · · · · · · · · ·physicians any of these

26· · · · · · · · · ·questions.· She has testified

27· · · · · · · · · ·that this was a draft that was

28· · · · · · · · · ·prepared that was going to be

29· · · · · · · · · ·reviewed by her managers and was

30· · · · · · · · · ·subsequently changed.· So --

31· · · · · · · · · ·BY MR. GOLDEN:

32· · · · · · · · · ·Q. Okay, that is fine.· I'll

Page 6942·1· · move on.

·2· · · · · · · · · ·If we can go back to your

·3· · affidavit and we go straight to paragraph

·4· · number 106, and this would be consistent with

·5· · what you have explained as really your

·6· · approach.· You go into these inspections

·7· · looking to see whether there is evidence of

·8· · compliance?

·9· · · · · · · · · ·A. Yes.

10· · · · · · · · · ·Q. And I take it that this --

11· · one of the unique features or unusual features

12· · of this particular inspection is that you were

13· · dealing with many incidents that happened many,

14· · many years prior to when you would typically be

15· · inspecting; is that fair to say?

16· · · · · · · · · ·A. Yes.

17· · · · · · · · · ·Q. And is it fair to say that

18· · when you are inspecting events that are much

19· · fresher, say, in response to a complaint

20· · investigation or an annual RQI, it is more

21· · likely in your experience that the persons that

22· · you are interviewing actually have a memory of

23· · the events that you are questioning them about?

24· · · · · · · · · ·A. That was a really long

25· · question.

26· · · · · · · · · ·Q. Is it fair to say that in

27· · your more typical inspections, when you are

28· · inspecting a more recent occurrence, it is more

29· · common for the persons you are interviewing to

30· · actually have a memory of the events that you

31· · are asking them about?

32· · · · · · · · · ·A. Yes.

Page 6943·1· · · · · · · · · ·Q. All right.· And so given that

·2· · you were asking these witnesses about events

·3· · that happened so long ago, how did you account

·4· · for the fact that although sometimes you might

·5· · get verbal evidence of compliance, in this case

·6· · it was much more unlikely to be able to get

·7· · verbal compliance because the events happened

·8· · so long ago?

·9· · · · · · · · · ·A. All I can say was I was asked

10· · to go in and do this inspection, and when we do

11· · an inspection, we gather evidence to support

12· · compliance by way of interviews, observations

13· · and record reviews.· That is my job.· That is

14· · what I did.

15· · · · · · · · · ·Q. Okay.· Could we turn then to

16· · the inspection that is at tab "J" in your

17· · affidavit, and that is 43372.

18· · · · · · · · · ·Now, Rhonda, the report date is

19· · January 24 and August 15, 2017, and I want to

20· · understand - and I think you clarified this for

21· · your counsel yesterday - that this licensee

22· · copy of the Inspection Report, it wouldn't

23· · actually have been given to the licensee until

24· · August 15th?

25· · · · · · · · · ·A. I clarified that with

26· · Commission Counsel --

27· · · · · · · · · ·Q. Yes.

28· · · · · · · · · ·A. -- yesterday, and the home

29· · had two Compliance Orders that were immediate

30· · orders that they received with the order and

31· · the grounds that included only current

32· · information.· They got that on January 24th.

Page 6944·1· · · · · · · · · ·They got the remainder of the

·2· · report on August 15th.

·3· · · · · · · · · ·Q. And I understand that, and

·4· · there were separate Compliance Orders dated

·5· · January 2017 that you went over with counsel,

·6· · correct, separate documents?

·7· · · · · · · · · ·A. Separate reports.

·8· · · · · · · · · ·Q. Right, and so I was asking

·9· · you specifically about this document, 43372,

10· · that has all of these Written Notifications in

11· · it.· This document would not have been provided

12· · to Caressant Care Woodstock until August 15th,

13· · 2017; is that correct?

14· · · · · · · · · ·A. This document, but they did

15· · have the grounds related to current issues for

16· · 131 and 135 in the orders.· They got those in

17· · January.

18· · · · · · · · · ·So I can't say they didn't get

19· · any of it.· They got pieces of it, but not --

20· · they got the rest of it August 15th.

21· · · · · · · · · ·Q. What they got before is in

22· · separate documentation that you went through

23· · with counsel; is that fair?· They didn't get

24· · this document?

25· · · · · · · · · ·A. They didn't get that

26· · document.

27· · · · · · · · · ·Q. All right.· So for example,

28· · they didn't get Written Notification number 14

29· · about Mr. Silcox; they didn't get that one?

30· · · · · · · · · ·A. That's correct.

31· · · · · · · · · ·Q. All right.· And in fact,

32· · could you just confirm that with respect to

Page 6945·1· · Written Notifications, whether there is a

·2· · Voluntary Plan of Correction or not, that is

·3· · not something that the licensee is able to ask

·4· · for a review or appeal?

·5· · · · · · · · · ·A. They can't appeal it, but

·6· · they can certainly ask questions about it, and

·7· · if they have a concern about that, I can't say

·8· · that it wouldn't be looked at, but that

·9· · wouldn't be my role.

10· · · · · · · · · ·Q. Okay, I understand, but you

11· · have done this long enough, I'm suggesting, to

12· · know that there is no appeal route or formal

13· · review route for a licensee when they get a

14· · Written Notification?

15· · · · · · · · · ·A. Right.

16· · · · · · · · · ·Q. And the same goes for a

17· · Voluntary Plan of Correction, there is no

18· · review route or appeal route that is provided

19· · for in the legislation?

20· · · · · · · · · ·A. That is my understanding.

21· · · · · · · · · ·Q. All right.· Can you turn to

22· · page 5 of 33 of this report.· Thank you.

23· · · · · · · · · ·It indicates 13 Written

24· · Notifications and five Voluntary Plan of

25· · Corrections; do you see that?

26· · · · · · · · · ·A. Yes.

27· · · · · · · · · ·Q. And is it fair to say that

28· · the five Voluntary Plan of Corrections are

29· · actually part of the 13?

30· · · · · · · · · ·A. Every finding of

31· · non-compliance is a Written Notification, and

32· · sometimes there is a Voluntary Plan of

Page 6946·1· · Correction that goes along with it; sometimes

·2· · there is a Compliance Order that goes along

·3· · with it; sometimes there is a Director's -- so

·4· · every non-compliance has a Written

·5· · Notification.

·6· · · · · · · · · ·Q. I understand, but just so

·7· · that it is not confusing to the public or

·8· · anyone else, if you look at the first two,

·9· · there is not 18 separate --

10· · · · · · · · · ·A. Yes, yes, so there wasn't

11· · five VPCs on top of the 13.

12· · · · · · · · · ·Q. Okay, thank you.

13· · · · · · · · · ·And if we now turn over to page

14· · 9, and this -- you gave some evidence about

15· · this, and this had to do with the Written

16· · Notification for the quarterly evaluations of

17· · the medication management system; do you

18· · remember that?

19· · · · · · · · · ·A. Yes.

20· · · · · · · · · ·Q. All right.· And you list on

21· · page 9 various persons that were interviewed

22· · which allowed you to form your conclusions; do

23· · you see that?

24· · · · · · · · · ·A. Yes.

25· · · · · · · · · ·Q. Were there other people that

26· · you also interviewed in connection with this

27· · issue of medication management system, or would

28· · they have been listed here?

29· · · · · · · · · ·A. There would only be evidence

30· · to support the non-compliance in the finding.

31· · · · · · · · · ·Q. All right, well, did you

32· · answer -- did you interview Sandra Fluttert

Page 6947·1· · about this?

·2· · · · · · · · · ·A. I interviewed Sandra

·3· · Fluttert.· I can't remember the questions we

·4· · asked her.· We would have to pull up that

·5· · interview.

·6· · · · · · · · · ·Q. Well, if you would have asked

·7· · her specifically about the medication

·8· · management system, would there have been a

·9· · reference on page 9 to the fact that she was

10· · also interviewed with respect to the issue of

11· · medication management system?

12· · · · · · · · · ·A. I don't know.· I -- all I can

13· · say is the evidence to support the

14· · non-compliance is documented in the finding.

15· · · · · · · · · ·Q. I understand --

16· · · · · · · · · ·A. If I didn't -- if she didn't

17· · provide me with evidence to support the

18· · non-compliance, I don't put evidence to support

19· · compliance in my finding of non-compliance, and

20· · I --

21· · · · · · · · · ·Q. So let me --

22· · · · · · · · · ·A. And if she had given me

23· · evidence to support the non-compliance, I might

24· · have added it, but when I am talking in this,

25· · this non-compliance, it lists specific people,

26· · so those are the specific people who are

27· · listed.

28· · · · · · · · · ·Q. So let me just understand

29· · what you are telling us.· When you are

30· · preparing a report, you only include the

31· · evidence that you obtained of non-compliance,

32· · but you don't include evidence from other

Page 6948·1· · people who support compliance; is that what you

·2· · are telling us?

·3· · · · · · · · · ·A. I can see what just happened

·4· · there.

·5· · · · · · · · · ·Q. That is the way I understood

·6· · it, so --

·7· · · · · · · · · ·A. And I understand that.· That

·8· · is just me explaining our processes.· If I had

·9· · a finding of non-compliance, I wouldn't have

10· · evidence to support compliance in the finding

11· · of non-compliance.

12· · · · · · · · · ·I am not inferring that Sandra

13· · Fluttert provided me with evidence to support

14· · compliance.

15· · · · · · · · · ·Q. Okay, well, can we have a

16· · look at document 43479, which was Exhibit 19 in

17· · the proceeding, in the Inquiry.

18· · · · · · · · · ·And I have an extra page.· This

19· · is 43479, and it is already Exhibit 19.

20· · · · · · · · · ·Now, Rhonda, this is your

21· · handwriting in the top left corner?

22· · · · · · · · · ·A. Yes.

23· · · · · · · · · ·Q. All right, so this is a

24· · document then that you would have received in

25· · your capacity as an Inspector back on November

26· · 4th of 2016; is that right?

27· · · · · · · · · ·A. Yes.

28· · · · · · · · · ·Q. All right.· And this talks

29· · about "Medication Management System Program

30· · Evaluation".· It was already introduced into

31· · evidence and discussed somewhat in the

32· · Facilities Phase.

Page 6949·1· · · · · · · · · ·Do you have a recollection of

·2· · interviewing Sandra Fluttert about this?

·3· · · · · · · · · ·A. No.

·4· · · · · · · · · ·Q. And is there a reason why

·5· · none of this information about the home's

·6· · medication management system program evaluation

·7· · makes it into your report?

·8· · · · · · · · · ·A. Because the finding reads:

·9· · · · · · · · · ·"The licensee has failed to

10· · · · · · · · · ·ensure that an interdisciplinary

11· · · · · · · · · ·team, which must include the

12· · · · · · · · · ·medical director, the

13· · · · · · · · · ·administrator, the director of

14· · · · · · · · · ·nursing and personal care, the

15· · · · · · · · · ·pharmacist and the pharmacy

16· · · · · · · · · ·service provider, and a

17· · · · · · · · · ·registered dietitian who is a

18· · · · · · · · · ·member of the staff at the home,

19· · · · · · · · · ·met quarterly to evaluate the

20· · · · · · · · · ·effectiveness of the medication

21· · · · · · · · · ·management system in the home

22· · · · · · · · · ·and to recommend any changes

23· · · · · · · · · ·necessary to improve the

24· · · · · · · · · ·system."

25· · · · · · · · · ·[As read.]

26· · · · · · · · · ·And this document that you

27· · provided me says that the review was completed

28· · by Sandra Fluttert by herself, so that tells me

29· · that this document doesn't say that - and I

30· · won't read it all over again - all those people

31· · participated in that program evaluation.

32· · · · · · · · · ·Q. Well, in fairness, it does

Page 6950·1· · say under number 1 that there is a

·2· · multidisciplinary team which meets at least

·3· · quarterly and that minutes of the team meetings

·4· · are documented, including results --

·5· · · · · · · · · ·[Reporter's Note:· An audience

·6· · · · · · · · · ·member's cell phone activates

·7· · · · · · · · · ·and makes an audible

·8· · · · · · · · · ·announcement].

·9· · · · · · · · · ·THE WITNESS:· Perfect.

10· · · · · · · · · ·BY MR. GOLDEN:

11· · · · · · · · · ·Q. Sometimes lawyers in this

12· · situation do call out for help, but that is not

13· · typically what we are looking for.

14· · · · · · · · · ·A. I would like to phone a

15· · friend right now.

16· · · · · · · · · ·THE COMMISSIONER:· Actually, I

17· · · · · · · · · ·would be interested to hear the

18· · · · · · · · · ·answer to your question.

19· · · · · · · · · ·BY MR. GOLDEN:

20· · · · · · · · · ·Q. Yes, so I wanted to know

21· · whether, you know, you considered what was

22· · written here as evidence of compliance and, if

23· · it wasn't clear, whether you talked to Sandra

24· · Fluttert about it?

25· · · · · · · · · ·A. I can't remember what I

26· · talked to Sandra Fluttert about, but this is

27· · one medication management system program

28· · evaluation that was provided to me by the home

29· · when we asked for the medication management

30· · system program evaluation.

31· · · · · · · · · ·And when I am looking for that,

32· · I am looking to make sure that the document

Page 6951·1· · that is provided meets the legislation that is

·2· · outlined here.

·3· · · · · · · · · ·And my decision at that time,

·4· · based on the information that is on this

·5· · document -- or rather, the lack of information

·6· · that I was looking for to support compliance

·7· · was in that document.

·8· · · · · · · · · ·So it doesn't tell me that they

·9· · were compliant.· It is not evidence to support

10· · compliance.

11· · · · · · · · · ·Q. I think it was very clearly

12· · explained by you earlier that this is certainly

13· · the most unique and intense inspection you have

14· · ever conducted?

15· · · · · · · · · ·A. Yes.

16· · · · · · · · · ·Q. Do you have any insight into

17· · why you were chosen to do this inspection?

18· · · · · · · · · ·A. I happened to be the lucky

19· · one who was in the office that day, along with

20· · Natalie Moroney.

21· · · · · · · · · ·Q. I think some lawyers could

22· · relate to that.

23· · · · · · · · · ·A. I should have bought a

24· · lottery ticket that day.

25· · · · · · · · · ·Q. Okay.· And I take it you were

26· · aware of, you know, the great expectations that

27· · were awaiting the release of your findings,

28· · more than a typical investigation or

29· · inspection?

30· · · · · · · · · ·A. I could assume that.

31· · · · · · · · · ·Q. And, well, were you aware of

32· · any inspection that was ever anticipated by the

Page 6952·1· · public, the media or the Ministry as much as

·2· · this one, in your experience?

·3· · · · · · · · · ·A. In my experience, no.

·4· · · · · · · · · ·Q. And were you aware of the

·5· · fact that Minister Hoskins had sent a letter

·6· · out to the sector that we looked at with Karen

·7· · Simpson the other day on January the 11th of

·8· · 2017?· And we can pull that up.· It is 56508.

·9· · · · · · · · · ·A. Can you tell me where that

10· · is?

11· · · · · · · · · ·Q. Yes, it is Exhibit 133, and

12· · it is January 11, 2017.· We'll pull it up on

13· · the screen.

14· · · · · · · · · ·A. Could you tell me where it is

15· · in my --

16· · · · · · · · · ·Q. It is not in your affidavit,

17· · no.

18· · · · · · · · · ·A. Oh.

19· · · · · · · · · ·THE COMMISSIONER:· Madam Clerk,

20· · · · · · · · · ·can you just have a copy of that

21· · · · · · · · · ·provided to the witness so she

22· · · · · · · · · ·can see it.

23· · · · · · · · · ·MR. GOLDEN:· Exhibit 133.

24· · · · · · · · · ·THE COMMISSIONER:· Thank you.

25· · · · · · · · · ·BY MR. GOLDEN:

26· · · · · · · · · ·Q. It should be Exhibit 133, and

27· · 46508 I think is the document number.· Yeah,

28· · this is 56 -- yeah.

29· · · · · · · · · ·You are aware of that?· You have

30· · seen that letter before?

31· · · · · · · · · ·A. I don't remember.· I might --

32· · it might have been sent to us, but I can't say.

Page 6953·1· · I don't remember seeing this.

·2· · · · · · · · · ·Q. Did you have a sense, Rhonda,

·3· · as you were going through this exercise that

·4· · there was a tremendous focus not only on the

·5· · home, but really the whole long-term care

·6· · system was being questioned for how this

·7· · tragedy could have happened?

·8· · · · · · · · · ·A. Definitely.

·9· · · · · · · · · ·Q. And did you have a sense as

10· · well that even within the Ministry, people were

11· · questioning how the Ministry's systems could

12· · have failed to detect this kind of crime?

13· · · · · · · · · ·A. Definitely.

14· · · · · · · · · ·Q. And in view of that, were you

15· · feeling any pressure different from your

16· · run-of-the-mill RQIs to actually find

17· · non-compliances?

18· · · · · · · · · ·A. No.· But there was a lot of

19· · pressure to do the right thing, to do my job

20· · well, to try not to miss anything in gathering

21· · evidence to either support compliance or

22· · support non-compliance, because when I do an

23· · inspection, I go in to gather evidence to

24· · support compliance, and if I can't find it, I

25· · need to have enough evidence to support

26· · non-compliance.

27· · · · · · · · · ·Q. Okay.

28· · · · · · · · · ·A. And both are equally

29· · difficult, and the pressure to do a good job

30· · for this, to represent those residents and

31· · those families was massive.

32· · · · · · · · · ·Q. I am sure it was. I

Page 6954·1· · understand that.

·2· · · · · · · · · ·It seems that the medication

·3· · management became a central concern which

·4· · really led to the orders on 131 and 135; is

·5· · that fair to say?

·6· · · · · · · · · ·A. Those were the ones that

·7· · orders were issued.

·8· · · · · · · · · ·Q. And that was because of the

·9· · 41 medication errors that were noticed from

10· · that August to December period, August to

11· · December 28th, I believe it was?

12· · · · · · · · · ·A. Coupled with a lack of

13· · evidence to support compliance with 135, which

14· · is taking appropriate actions and reporting and

15· · analyzing those 41 medication incidents.

16· · · · · · · · · ·Q. And with respect to those

17· · incidents, did you give any different

18· · consideration to those that happened between

19· · October 5th, 2016, and December 28th, 2016?

20· · · · · · · · · ·A. No.· But I am not allowed to

21· · do that.

22· · · · · · · · · ·Q. I understand.· And those --

23· · there were quite a number that I recall in the

24· · notes where it said medication wasn't given.

25· · Is that possible as well, that medication was

26· · given but the giving of it wasn't charted in

27· · Point Click Care?

28· · · · · · · · · ·A. I can't say.

29· · · · · · · · · ·Q. Okay.· If we can turn to

30· · document 39100, and that is the management

31· · order that you were looking at before we broke.

32· · · · · · · · · ·A. Can you tell me where that

Page 6955·1· · is?

·2· · · · · · · · · ·Q. It would be in the -- it is

·3· · in Karen's -- it is Exhibit "S" to Karen

·4· · Simpson's affidavit, but it was also in the

·5· · brief, Exhibit "L" -- "M", sorry, "M".

·6· · · · · · · · · ·A. Would I have that somewhere

·7· · in this pile of stuff?

·8· · · · · · · · · ·Q. Yes.

·9· · · · · · · · · ·A. Could you tell me where that

10· · is?

11· · · · · · · · · ·Q. Sure.

12· · · · · · · · · ·MS. STEPHENS:· In Part 2 of your

13· · · · · · · · · ·affidavit, Exhibit "M".

14· · · · · · · · · ·THE WITNESS:· Okay.

15· · · · · · · · · ·BY MR. GOLDEN:

16· · · · · · · · · ·Q. Now, I think you clarified in

17· · answers to questions posed by my friend that

18· · this was drafted at a higher level?· You

19· · weren't involved in the actual language of the

20· · drafting here?

21· · · · · · · · · ·A. No, because it is titled

22· · "Orders of the Director", and I am not the

23· · Director.

24· · · · · · · · · ·Q. I understand.· If you turn

25· · over to page number 7 and we go down to the

26· · section called "Medication Administration"?

27· · · · · · · · · ·A. Yes.

28· · · · · · · · · ·Q. There is a reference in the

29· · first bullet point to an order, and if we go

30· · the third line from the bottom:

31· · · · · · · · · ·"This Order was not complied

32· · · · · · · · · ·with and on August 24, 2017, was

Page 6956·1· · · · · · · · · ·re-issued for a second time with

·2· · · · · · · · · ·a compliance date of September 8

·3· · · · · · · · · ·[...] and referred to the

·4· · · · · · · · · ·Director."

·5· · · · · · · · · ·Do you see that?

·6· · · · · · · · · ·A. Yes.

·7· · · · · · · · · ·Q. And the order that was made

·8· · on August 24th, that was your order?· You did

·9· · that inspection, right?

10· · · · · · · · · ·A. With another Inspector.

11· · · · · · · · · ·Q. Okay.· And I am not going to

12· · take you to it.· We went through it the other

13· · day.· But you and the other Inspector had set a

14· · compliance date of September 8th; do you see

15· · that?

16· · · · · · · · · ·A. I see that there.

17· · · · · · · · · ·Q. Okay.· And if we go down to

18· · the next bullet point, there is a reference to

19· · another order, and the third-last line says:

20· · · · · · · · · ·"This Order was not complied

21· · · · · · · · · ·with and on August 24 [...] was

22· · · · · · · · · ·re-issued to the licensee with a

23· · · · · · · · · ·compliance date of September 8th

24· · · · · · · · · ·[...]"

25· · · · · · · · · ·Do you see that?

26· · · · · · · · · ·A. I do.

27· · · · · · · · · ·Q. And that, again, was the

28· · order that you and your colleague had prepared

29· · and you and your colleague had set that

30· · compliance date of September 8th; is that

31· · right?

32· · · · · · · · · ·A. That is what it says.

Page 6957·1· · · · · · · · · ·Q. Okay.· And then if we go over

·2· · to the next page, there is another order also

·3· · dated also on August 24th and was re-issued

·4· · with a compliance date of September 8th; do you

·5· · see that?

·6· · · · · · · · · ·A. I see that.

·7· · · · · · · · · ·Q. And that was your order and

·8· · your colleague's order from August, right,

·9· · August the --

10· · · · · · · · · ·A. It looks that way.

11· · · · · · · · · ·Q. Yes, okay.· So what I want to

12· · understand is this.· On August the 24th, you

13· · issued an order and gave it to the home which

14· · set a deadline for compliance of September 8th;

15· · correct?

16· · · · · · · · · ·A. It looks that way.

17· · · · · · · · · ·Q. All right.· And the

18· · management order we know was made on September

19· · the 1st; correct?· If you turn to the very last

20· · page, page 11, we'll see Karen Simpson's

21· · signature?

22· · · · · · · · · ·A. I see that.

23· · · · · · · · · ·Q. And it says September 1,

24· · 2017.

25· · · · · · · · · ·And what I want to know is

26· · whether between August 24th, when you made your

27· · order and gave the home a September 8th

28· · compliance date, did you go back to the home

29· · and say, No, no, you don't have until September

30· · 8th; you only have until August 31st or

31· · September 1st, or something like that?· Do you

32· · have any recollection of doing that?

Page 6958·1· · · · · · · · · ·A. I don't know why I would do

·2· · that.

·3· · · · · · · · · ·Q. Well, why you would do that

·4· · is because you had given the home an order and

·5· · said that they had until September 8th to

·6· · comply, and yet the Ministry is taking away

·7· · that opportunity to comply on September 1st.

·8· · · · · · · · · ·And so I would like to know

·9· · whether you have any knowledge of informing the

10· · home before this management order was made that

11· · that compliance date was going to change or was

12· · no longer valid?

13· · · · · · · · · ·MR. KLOEZE:· Commissioner, I

14· · · · · · · · · ·think, again, Mr. Golden is

15· · · · · · · · · ·mischaracterizing or

16· · · · · · · · · ·misunderstanding Ms. Kukoly's

17· · · · · · · · · ·role in this.

18· · · · · · · · · · · The order, the Mandatory

19· · · · · · · · · ·Management Order that he is

20· · · · · · · · · ·referring to here is not the

21· · · · · · · · · ·order of Ms. Kukoly.

22· · · · · · · · · ·BY MR. GOLDEN:

23· · · · · · · · · ·Q. I understand that, and I

24· · simply want to know whether you at any point

25· · after you made your August 24th order were

26· · instructed or on your own went back to the home

27· · and said the September 8th deadline that I gave

28· · you is no longer the deadline; did you do that?

29· · · · · · · · · ·A. It is my understanding that

30· · the September 8th deadline was the deadline and

31· · it didn't change.

32· · · · · · · · · ·Q. Okay.

Page 6959·1· · · · · · · · · ·A. And I didn't go to the home

·2· · and tell them any different than that.

·3· · · · · · · · · ·Q. Okay.· Was there any

·4· · additional inspection or crisis that you are

·5· · aware of that occurred between August 24th and

·6· · September 1st?· Because I haven't seen any

·7· · reports of an inspection or a crisis occurring

·8· · between August 24th and September 1st.

·9· · · · · · · · · ·A. I don't know what you are

10· · talking about, I am sorry.

11· · · · · · · · · ·Q. Well, I haven't seen it

12· · either, so I am asking you if you have any

13· · knowledge of an incident, an inspection or a

14· · crisis that happened in the home from August

15· · the 24th until September 1st?

16· · · · · · · · · ·A. Not to my knowledge.

17· · · · · · · · · ·Q. I just have a couple more

18· · questions, Rhonda, and one of them really came

19· · from thinking about an answer that you gave to

20· · Commission Counsel two days ago that I was

21· · really struck by.

22· · · · · · · · · ·And counsel was asking you

23· · questions about doing your inspections and

24· · observing care being given and circumstances,

25· · how you would evaluate things, and I wrote down

26· · your words, because she asked you about the

27· · regulatory context and you said:· I am having

28· · trouble thinking of an area that wouldn't fall

29· · neatly into some regulation.

30· · · · · · · · · ·Do you remember saying that?

31· · · · · · · · · ·A. That was in the context of

32· · her question what would we do, and I wasn't

Page 6960·1· · able to in that time think of an example of

·2· · that to be able to answer that.

·3· · · · · · · · · ·Q. Okay.· I guess what struck me

·4· · was this notion that, you know, there has to be

·5· · or that there would be some regulation that

·6· · would, you know, fit neatly with every

·7· · situation.

·8· · · · · · · · · ·And my question to you is this.

·9· · Do you think that it is a hindrance to

10· · professional staff who work in long-term care,

11· · rather than going with their professional

12· · judgment, to have to think each time they

13· · interact with a resident, is there some

14· · regulation that this falls into that I have to

15· · turn my mind to compliance or non-compliance

16· · before I deal with the resident?

17· · · · · · · · · ·A. I am really sorry, I am not

18· · trying to be difficult, but that was a really

19· · long question and I kind of lost the intent of

20· · it.

21· · · · · · · · · ·The only thing that is coming to

22· · my mind right now was that Commission Counsel,

23· · those were her words in choosing that an

24· · example of something that didn't fit neatly

25· · into that legislation, and those weren't my

26· · words.

27· · · · · · · · · ·Q. I think you said you were

28· · having trouble thinking of an area that

29· · wouldn't fit neatly into some regulation.

30· · · · · · · · · ·A. Because Commission Counsel

31· · asked me about an area that didn't fit neatly

32· · into the legislation.

Page 6961·1· · · · · · · · · ·Q. But what I am really asking

·2· · is this.· If we try and create a regulation for

·3· · everything, do you think that that hinders

·4· · health care professionals' ability to exercise

·5· · their professional judgment about how to

·6· · interact with residents and care for residents

·7· · without having to go through the step in their

·8· · head, oh, there must be some regulation

·9· · applying to this situation, I had better comply

10· · with it?· That is my question, and I think it

11· · is a broader one for this Commission to

12· · consider.

13· · · · · · · · · ·A. I agree, it is a broader one

14· · for the Commission to consider.· It is not for

15· · me to say.

16· · · · · · · · · ·Q. But you are a nurse.· You

17· · have worked on both sides.· So do you not have

18· · a view on whether everything needs to be

19· · regulated?

20· · · · · · · · · ·A. It doesn't matter what my

21· · view is.· That is the system that I am working

22· · in, and I have to fulfil my obligations as an

23· · Inspector.· And I don't get to choose what is

24· · in the regulations.

25· · · · · · · · · ·MR. GOLDEN:· Thank you, Rhonda,

26· · · · · · · · · ·I have nothing further.

27· · · · · · · · · ·THE COMMISSIONER:· Thank you,

28· · · · · · · · · ·Mr. Golden.

29· · · · · · · · · ·CROSS-EXAMINATION BY MS. FRASER:

30· · · · · · · · · ·Q. I'm going to try to call you

31· · Rhonda.· My name is Suzan Fraser.· I'm here on

32· · behalf of OARC.

Page 6962·1· · · · · · · · · ·Just picking up on Mr. Golden's

·2· · questions that he finished with, you understand

·3· · from working in long-term care for a

·4· · significant period of time and having the

·5· · legislation at your fingertips, per part of

·6· · your daily practice, that the Act and the

·7· · preamble to the Act set out that the people of

·8· · Ontario and their Government firmly believe in

·9· · public accountability and transparency to

10· · demonstrate that long-term care homes are

11· · governed and operated in a way that reflects

12· · the interests of the public and promotes

13· · effective and efficient delivery of high

14· · quality services to all residents, right?· That

15· · is in the preamble to the Act?

16· · · · · · · · · ·A. In not seeing that at the

17· · present time, I would have to take your word

18· · for that, that that's what it says.

19· · · · · · · · · ·Q. Okay, and --

20· · · · · · · · · ·A. I don't have it memorized.

21· · · · · · · · · ·Q. Do you have your copy of the

22· · legislation with you?· I know you had it with

23· · you yesterday.

24· · · · · · · · · ·A. I do.

25· · · · · · · · · ·Q. Okay, so at any time, if you

26· · want to just look at your legislation to

27· · clarify, but that is -- I'm reading from the

28· · Act.· But that is how you approach your job

29· · every day, right?· You know that you are there

30· · as a public servant to fulfil a public

31· · accountability and transparency role?

32· · · · · · · · · ·A. Yes.

Page 6963·1· · · · · · · · · ·Q. Right.· Your work gets posted

·2· · on a public website, right?

·3· · · · · · · · · ·A. It does.

·4· · · · · · · · · ·Q. So what you do gets reviewed

·5· · by many, many, many people.· It can be

·6· · appealed, right?

·7· · · · · · · · · ·A. Yes.

·8· · · · · · · · · ·Q. Anybody can access your work

·9· · product by going --

10· · · · · · · · · ·A. Part of it.

11· · · · · · · · · ·Q. Part of it.

12· · · · · · · · · ·A. Because only a public report

13· · gets posted publicly, which is different than

14· · the report that the home gets, the licensee

15· · report.

16· · · · · · · · · ·Q. Right.

17· · · · · · · · · ·A. And we take great measures to

18· · review and I don't want to say redact, but to

19· · remove any personal health information that

20· · could reveal anything related to the

21· · resident --

22· · · · · · · · · ·Q. Yes.

23· · · · · · · · · ·A. -- when -- to create a public

24· · report that is separate from the licensee

25· · report so that we are not violating anyone's

26· · privacy.

27· · · · · · · · · ·Q. Yes.

28· · · · · · · · · ·A. I actually had a really

29· · difficult time seeing my licensee reports up

30· · there, because all of that had to be removed to

31· · post it publicly to respect the privacy of

32· · those residents, and some of them are still --

Page 6964·1· · could be still in the home.

·2· · · · · · · · · ·Q. Right.· Right, so but your

·3· · thoughts and your analysis in terms of how you

·4· · approach your job, that has a public and

·5· · transparent role when it gets posted to the

·6· · website, right?

·7· · · · · · · · · ·A. It does.

·8· · · · · · · · · ·Q. Okay.· So you don't get to

·9· · pick and choose whether the philosophy behind

10· · the legislation is correct.· You are there to

11· · say, I understand that part of our system is

12· · about ensuring the safety of residents and

13· · public accountability, right?

14· · · · · · · · · ·A. Yes.

15· · · · · · · · · ·Q. Okay.· So now I am just going

16· · to deal with the other question that Mr. Golden

17· · raised.· He raised the issue of the order of

18· · the Director and the September deadline for

19· · some of the Compliance Orders.

20· · · · · · · · · ·And we can turn that document

21· · up.· It is document 39100.· And I think it is

22· · in your affidavit, but that is Karen Simpson's

23· · order.

24· · · · · · · · · ·A. Which one?

25· · · · · · · · · ·THE COMMISSIONER:· Exhibit "M".

26· · · · · · · · · ·MS. FRASER:· Exhibit "M".

27· · · · · · · · · ·MS. STEPHENS:· It is tab "M".

28· · · · · · · · · ·THE COMMISSIONER:· Tab "M" to

29· · · · · · · · · ·your affidavit.

30· · · · · · · · · ·BY MS. FRASER:

31· · · · · · · · · ·Q. And I just want to -- you

32· · were taken to I believe some of the September

Page 6965·1· · 8th compliance dates that fall on page -- at

·2· · least in my version, I think it is page 7.

·3· · · · · · · · · ·But you'll agree with me in

·4· · reviewing that order --

·5· · · · · · · · · ·A. Can I get there first?

·6· · · · · · · · · ·Q. Yes.· I mean, as you get

·7· · there, if you can look to the many other

·8· · compliance dates that are in that order?

·9· · · · · · · · · ·A. Do you want me to look at all

10· · of them now?

11· · · · · · · · · ·Q. Sorry, so here we are on page

12· · 7, and you were taken to an order being

13· · re-issued for a second time with a compliance

14· · date of September the 8th, right?

15· · · · · · · · · ·A. I see that.

16· · · · · · · · · ·Q. Okay, and there is numerous

17· · September the 8th deadlines.· Some of these are

18· · the second orders for compliance, as I

19· · understand it, right?

20· · · · · · · · · ·A. It looks that way.

21· · · · · · · · · ·Q. Okay, because you are

22· · re-issuing it?

23· · · · · · · · · ·A. It looks that way.

24· · · · · · · · · ·Q. Okay, and that means that it

25· · wasn't complied with before?

26· · · · · · · · · ·A. Yes.

27· · · · · · · · · ·Q. And that is why you have to

28· · re-issue it?

29· · · · · · · · · ·A. Yes.

30· · · · · · · · · ·Q. Okay, and if you also go to

31· · some of the other parts of that order of the

32· · Director, you can look above to, for example,

Page 6966·1· · the one above, "Protecting Residents From Abuse

·2· · and Neglect"?

·3· · · · · · · · · ·A. Yes.

·4· · · · · · · · · ·Q. Thank you, Laura.

·5· · · · · · · · · ·You see there that there is a

·6· · compliance date in the first paragraph of

·7· · January 27th.· That order was determined to be

·8· · complied with in May 2017.· But looking down,

·9· · in the last paragraph it says that on May 24th,

10· · 2017, Compliance Orders was issued with a

11· · compliance date of June 30th, 2017?

12· · · · · · · · · ·A. Yes, I can see that.

13· · · · · · · · · ·Q. Right?· So within this order

14· · of the Director, she is examining a number of

15· · different Compliance Orders, most of which have

16· · dates for compliance prior to September the

17· · 1st, 2017; is that fair?

18· · · · · · · · · ·A. That is what's on there.

19· · · · · · · · · ·Q. Okay.· So we are going to

20· · leave that now.· That is all I wanted to

21· · clarify.

22· · · · · · · · · ·I want to just talk about when

23· · you became an Inspector, okay.· And I

24· · appreciate what a difficult job this is being a

25· · witness, I really do, because you are having to

26· · listen to the question and you are having to

27· · think about it.· So I appreciate that.

28· · · · · · · · · ·So I am moving to a different

29· · area that is going to take you away from these

30· · inspections for a moment and just to when you

31· · became an Inspector, okay.

32· · · · · · · · · ·And I have actually,

Page 6967·1· · Commissioner, just a few documents.

·2· · · · · · · · · ·THE COMMISSIONER:· Thank you.

·3· · · · · · · · · ·BY MS. FRASER:

·4· · · · · · · · · ·Q. You were a Director of Care

·5· · before you became an Inspector in London; is

·6· · that right?

·7· · · · · · · · · ·A. Yes.

·8· · · · · · · · · ·Q. Okay, and was that a profit

·9· · or not-for-profit home?

10· · · · · · · · · ·A. Not-for-profit.

11· · · · · · · · · ·Q. Okay.· And so it was neither

12· · the Jarlette nor a Caressant Care home, right?

13· · · · · · · · · ·A. No.

14· · · · · · · · · ·Q. Okay, and when you became --

15· · my interest is in the Residents' Council

16· · Interview Inspection Protocol, so I am going to

17· · ask you some questions about a protocol that

18· · existed in 2010 and then how that Residents'

19· · Council inspection -- Interview Inspection

20· · Protocol changed in 2014.

21· · · · · · · · · ·So at tabs 1, 2 and 3 of the

22· · document brief that I have put before you there

23· · are three different Inspection Protocols, and

24· · we are just going to look at how they changed

25· · over time, okay.

26· · · · · · · · · ·So just what we are doing here

27· · is we are just showing how these documents

28· · changed over time and whether you were familiar

29· · with them or not at the time, okay?

30· · · · · · · · · ·A. Okay.

31· · · · · · · · · ·Q. So if you could turn to the

32· · first document, that is tab 31717.· And if you

Page 6968·1· · look in the bottom corner of that document,

·2· · there is a date of September the 9th, 2017 --

·3· · sorry, 2010.

·4· · · · · · · · · ·And, Commissioner, I understand

·5· · this to be one of the source documents of the

·6· · Ministry Overview Report.

·7· · · · · · · · · ·And were you familiar prior

·8· · to -- or when you came in in 2013 and before

·9· · 2014 of working with a Residents' Council

10· · Interview Inspection Protocol?

11· · · · · · · · · ·A. Yes.

12· · · · · · · · · ·Q. Okay.· And so if we look at

13· · this document, we are just going to go through

14· · it starting on page 3, and we see that Part A

15· · deals with the "Residents' Council".

16· · · · · · · · · ·Part B deals with the

17· · "Assistant's Duties"; you would agree?

18· · · · · · · · · ·A. Yes.

19· · · · · · · · · ·Q. And Part C on page 4 deals

20· · with "Residents' Council Rights"?

21· · · · · · · · · ·A. Yes.

22· · · · · · · · · ·Q. Part D deals with "Residents'

23· · Council Powers"?

24· · · · · · · · · ·A. Yes.

25· · · · · · · · · ·Q. Okay, and in total in that

26· · document there are 29 areas for questions; do

27· · you agree?

28· · · · · · · · · ·A. Yes.

29· · · · · · · · · ·Q. Okay.· And when you were

30· · inspecting in 2013 and part of 2014, did you

31· · have occasion to ask questions under Part D of

32· · the Inspection Protocol?· So that is going back

Page 6969·1· · to page 5.

·2· · · · · · · · · ·A. I think so.

·3· · · · · · · · · ·Q. Okay.· And do you recall

·4· · those questions changing over time when the

·5· · protocols changed in 2014?

·6· · · · · · · · · ·A. I actually don't.

·7· · · · · · · · · ·Q. You don't, okay.

·8· · · · · · · · · ·Well, then if we could just turn

·9· · then, Commissioner, there is a second document

10· · at tab 2 which is not a source document and,

11· · given her answer on that question, I am not

12· · going to take her to it.· I am going to take

13· · her to the second source document, which is at

14· · tab 3.

15· · · · · · · · · ·So if you could turn to tab 3,

16· · and if we could go to page -- oh, sorry, that

17· · is at document, Laura, thank you, 31807.

18· · · · · · · · · ·And if you could go to page 3 of

19· · that document, please, you will see just -- and

20· · we'll go through the same sets of questions.

21· · Looking at Part A, it deals with "Residents'

22· · Council"; looking at page 4, I believe, of that

23· · document, we have "Assistant's Duties" and

24· · "Residents' Council Rights"?

25· · · · · · · · · ·A. Yes.

26· · · · · · · · · ·Q. And Part D, which was before

27· · we looked at as "Residents' Council Powers",

28· · and Part D now deals with "No Interference By

29· · Licensee "; do you agree?

30· · · · · · · · · ·A. It looks that way.

31· · · · · · · · · ·Q. Yes, and then if you turn to

32· · the last page, the last two pages, you will see

Page 6970·1· · that there appear only to be 18 questions in

·2· · this protocol?

·3· · · · · · · · · ·A. That is what it looks like to

·4· · me.

·5· · · · · · · · · ·Q. Okay.· And so just having

·6· · looked at both of those two documents, the one

·7· · that is 2010 on the bottom left-hand corner and

·8· · this one that has September 2014 on the bottom

·9· · left-hand corner, do you recall now whether

10· · there was a change in the types of questions

11· · that were asked about with the Residents'

12· · Council?

13· · · · · · · · · ·A. I'm sorry, I don't recall.

14· · · · · · · · · ·Q. Okay, thank you very much.

15· · · · · · · · · ·Do you agree, however, that when

16· · you are asking questions either with a

17· · Residents' Council or with a nurse or a

18· · Director of Care, that by asking those

19· · questions and asking them about particular

20· · issues, that does allow the person that you are

21· · asking questions to to learn about the

22· · legislation?

23· · · · · · · · · ·A. Yes.

24· · · · · · · · · ·Q. Okay.· And you have talked

25· · about looking for evidence to support

26· · compliance, and that is partly because somebody

27· · might not necessarily name something as a

28· · particular legislative role they are fulfilling

29· · or they might not say, I'm doing this in

30· · accordance with this part of the regulation,

31· · but they might know that they do that as part

32· · of their practice or they might learn that what

Page 6971·1· · they have been doing is something that is

·2· · expected by the regulations?

·3· · · · · · · · · ·A. Yes.

·4· · · · · · · · · ·Q. Okay.· So you talked about

·5· · the education part of the inspection process

·6· · and the exit interviews that you do, I'm

·7· · calling them exit interviews, and I think you

·8· · talked about an exit protocol.· Maybe that is

·9· · not the right word, but that you do with the

10· · Administrators?

11· · · · · · · · · ·A. Yes, it could be with whoever

12· · the home chooses to have there.

13· · · · · · · · · ·Q. Okay, and that is basically a

14· · debrief about what the findings are and what

15· · your expectations are going forward; is that

16· · fair?

17· · · · · · · · · ·A. Yes.

18· · · · · · · · · ·Q. Okay.· Is there a similar

19· · debrief with the Residents' Council?· We know

20· · they get a copy of the report under the

21· · legislation, I believe, but do you actually

22· · debrief with the Residents' Council?

23· · · · · · · · · ·A. Typically, no.

24· · · · · · · · · ·Q. Okay, and do you think that

25· · would be a good idea?

26· · · · · · · · · ·A. Yes.

27· · · · · · · · · ·Q. Okay, because if the

28· · Residents' Council is alive to the expectations

29· · of the Ministry with respect to that particular

30· · home, then they might be able to speak out

31· · about an issue if they see non-compliance; is

32· · that fair?

Page 6972·1· · · · · · · · · ·A. At the exit interview?

·2· · · · · · · · · ·Q. No, if the Residents' Council

·3· · was given a similar opportunity to debrief

·4· · about an inspection --

·5· · · · · · · · · ·A. Yes.

·6· · · · · · · · · ·Q. -- that might allow them to

·7· · have a better understanding of the Ministry's

·8· · expectations going forward from an inspection?

·9· · · · · · · · · ·A. I am going to disagree to

10· · that because the exit interviews are very high

11· · level.

12· · · · · · · · · ·Q. Yes.

13· · · · · · · · · ·A. And we typically don't review

14· · all of our grounds to support the

15· · non-compliance.

16· · · · · · · · · ·Q. All right.

17· · · · · · · · · ·A. And that is essentially a

18· · preliminary decision.· Like that is what we

19· · know at that time.

20· · · · · · · · · ·We go back and complete the

21· · judgment matrix, and especially if it is an RQI

22· · or if a team is involved, I don't necessarily

23· · know all of the grounds that another Inspector

24· · might have included in their findings.

25· · · · · · · · · ·And when we go through the

26· · judgment matrix, we also review the grounds,

27· · and we would have a discussion about that to

28· · make sure, yes, those grounds do support that

29· · area of legislation and that finding of

30· · non-compliance or, do you know what, I'm

31· · thinking that maybe that needs to be somewhere

32· · else, or I'm not sure that you have strong

Page 6973·1· · enough evidence to issue that.· That does

·2· · happen, and that might get removed.

·3· · · · · · · · · ·So for that reason, we don't get

·4· · into -- it is very little detail in an exit

·5· · debrief.

·6· · · · · · · · · ·Q. Okay, so let me -- let's

·7· · leave the exit debrief aside.· I am trying to

·8· · think about would it be good, just coming back

·9· · to I think one of the first questions that I

10· · had, it would be good for there to be a debrief

11· · about the findings of an Inspector with the

12· · Residents' Council?

13· · · · · · · · · ·A. And I said yes.

14· · · · · · · · · ·Q. Right, and do you agree with

15· · me that having that opportunity to meet with an

16· · Inspector would allow the residents to learn

17· · more about what the Ministry's expectations are

18· · of the home?

19· · · · · · · · · ·A. Yes.

20· · · · · · · · · ·Q. And that that in the future

21· · can have a protective role because it is a

22· · learning opportunity for the Residents'

23· · Council, and they know what is expected of the

24· · home, and so that if they are not seeing that,

25· · then they could make a report, for example?

26· · · · · · · · · ·A. Yes.

27· · · · · · · · · ·Q. Okay.· In the course of any

28· · of your inspections, did you ever meet with Jim

29· · Lavelle?

30· · · · · · · · · ·A. No.

31· · · · · · · · · ·Q. No.· And was he ever present

32· · at the home for any of the inspections?

Page 6974·1· · · · · · · · · ·A. If he was, I didn't see him.

·2· · · · · · · · · ·Q. Okay.· In the period of time

·3· · when you arrived in the home on October the

·4· · 5th, Brenda Van Quaethem had retired just days

·5· · before, right?

·6· · · · · · · · · ·A. Yes.

·7· · · · · · · · · ·Q. And there was no

·8· · Administrator in the home, right?

·9· · · · · · · · · ·A. On October the 5th.

10· · · · · · · · · ·Q. Right, there was nobody

11· · employed in the role of Administrator?

12· · · · · · · · · ·A. Not that I know of.

13· · · · · · · · · ·Q. Right, and I guess my

14· · question is, it is my understanding that every

15· · home has to have an Administrator under the

16· · Act?

17· · · · · · · · · ·A. Yes.

18· · · · · · · · · ·Q. Okay, but there wasn't a --

19· · that you didn't make a finding of

20· · non-compliance about that?

21· · · · · · · · · ·A. No.

22· · · · · · · · · ·Q. Okay.· I want to take you to

23· · you were asked a number of different questions

24· · about the interviews that you conducted, and I

25· · understand that you did conduct some interviews

26· · with family members and you talked about that

27· · yesterday and how difficult that was?

28· · · · · · · · · ·A. Yes.

29· · · · · · · · · ·Q. Okay.· And sometimes you

30· · performed the role of interviewer and sometimes

31· · you performed the role of note-taker?

32· · · · · · · · · ·A. For the most part I was the

Page 6975·1· · note-taker.

·2· · · · · · · · · ·Q. Okay.· And when you made

·3· · those notes, were they made as ad hoc notes?

·4· · · · · · · · · ·A. They were documented in a

·5· · Word doc.

·6· · · · · · · · · ·Q. Right.

·7· · · · · · · · · ·A. And then they got put into

·8· · the inspection.· Sometimes they got put into

·9· · the ad hoc notes, and sometimes they went

10· · directly into an individual IP.

11· · · · · · · · · ·But because we interviewed many

12· · different people about many different things

13· · and many different residents, in order for them

14· · to be in each individual IP, we would have to

15· · go through each one and put it in and it would

16· · have been relating to other residents.

17· · · · · · · · · ·And so I can't even remember

18· · where all I put them.· I probably put them in

19· · many -- too many places.

20· · · · · · · · · ·Q. Okay, well, I found an

21· · interview that you had with Wayne Hedges'

22· · family in your ad hoc notes, which is document

23· · 43003.· 43003.· It is at tab 4, the excerpt

24· · that I am going to take you to.

25· · · · · · · · · ·A. Yes.

26· · · · · · · · · ·Q. And do you have an

27· · independent recollection of your conversation

28· · with the sister of Wayne Hedges?

29· · · · · · · · · ·A. I didn't until I saw it up on

30· · the screen when -- during the Coroner.

31· · · · · · · · · ·Q. Okay, so you were here for

32· · that?

Page 6976·1· · · · · · · · · ·A. I wasn't here for that.

·2· · · · · · · · · ·Q. Oh, you were watching the

·3· · webcast?

·4· · · · · · · · · ·A. Yes.

·5· · · · · · · · · ·Q. Okay.· So --

·6· · · · · · · · · ·A. Part of it.

·7· · · · · · · · · ·Q. And in preparing for

·8· · questions, have you had a chance to review

·9· · these ad hoc notes?

10· · · · · · · · · ·A. When I saw that up there, I

11· · read it over.

12· · · · · · · · · ·Q. Okay.

13· · · · · · · · · ·A. But I honestly thought, oh,

14· · my gosh, I -- if Suzan Fraser would have asked

15· · me about that that day, I didn't remember it.

16· · I know we interviewed the families, but I

17· · didn't remember it.

18· · · · · · · · · ·Q. It is not really a memory

19· · quiz.· One of the reasons that you document --

20· · · · · · · · · ·A. That's a good thing.

21· · · · · · · · · ·Q. -- is so that if you need to

22· · refer back to something as an Inspector, you

23· · have made notes at the time, right?

24· · · · · · · · · ·A. That's a good point.

25· · · · · · · · · ·Q. And if they are good notes,

26· · you have documented what you heard and what you

27· · are thinking; and then perhaps in another place

28· · you might document what your thinking is about

29· · it or a reason for doing something, right?

30· · Documentation helps you do your job?

31· · · · · · · · · ·A. Yes, but it is rare that we

32· · document our thinking or our rationale.

Page 6977·1· · · · · · · · · ·Q. That would come in a

·2· · Compliance Order or your Inspection Summary,

·3· · right?

·4· · · · · · · · · ·A. And sometimes in the judgment

·5· · matrix --

·6· · · · · · · · · ·Q. Yes.

·7· · · · · · · · · ·A. -- where that decision-making

·8· · is done, especially if there is a variance from

·9· · the default.

10· · · · · · · · · ·Q. I don't need to have too

11· · much.· I just -- I'm okay with people

12· · refreshing their memory based on --

13· · · · · · · · · ·A. Got it.

14· · · · · · · · · ·Q. -- the notes they took at the

15· · time, and that is a very common practice.

16· · · · · · · · · ·Okay, so just my understanding,

17· · if we can turn then to page -- we are at page

18· · 43, please.

19· · · · · · · · · ·A. 43 of 67?

20· · · · · · · · · ·Q. Yes, and so the very first --

21· · the second page in your tab 4 --

22· · · · · · · · · ·A. Yes.

23· · · · · · · · · ·Q. -- should be the details

24· · about the Hedges interview that I want to take

25· · you to, okay?

26· · · · · · · · · ·A. Uhm-hmm.

27· · · · · · · · · ·Q. So we are going to go to the

28· · bottom of that page, Laura.

29· · · · · · · · · ·And the question was asked to

30· · Ms. Hedges, Mr. Hedges' sister:

31· · · · · · · · · ·"At any time did your parents

32· · · · · · · · · ·ever express any concerns as to

Page 6978·1· · · · · · · · · ·whether or not they knew her or

·2· · · · · · · · · ·had [any] concerns about her?"

·3· · · · · · · · · ·And then the answer appears to

·4· · be:

·5· · · · · · · · · ·"Nope, no, not to my knowledge

·6· · · · · · · · · ·[...]"

·7· · · · · · · · · ·And then there is -- you

·8· · indicate that the interview is -- not you, but

·9· · I mean you and Ms. MacDonald --

10· · · · · · · · · ·A. I understand.

11· · · · · · · · · ·Q. -- are saying that:

12· · · · · · · · · ·"We are concluding the

13· · · · · · · · · ·interview.· Is there anything

14· · · · · · · · · ·you would like to add?"

15· · · · · · · · · ·And am I right in reading these

16· · notes that what follows is a back and forth?

17· · You don't put question/answer, question/answer,

18· · that we have to interpret what is the question

19· · and what is the answer from these notes?

20· · · · · · · · · ·A. Yes, unfortunately.

21· · · · · · · · · ·Q. No, not a problem.· So I am

22· · going to read you the back and forth:

23· · · · · · · · · ·"Can I ask a question?· Of

24· · · · · · · · · ·course you can.· I don't know if

25· · · · · · · · · ·this is anything you can tell me

26· · · · · · · · · ·or if I have to wait.· We're

27· · · · · · · · · ·going to see the crown attorney

28· · · · · · · · · ·in a couple of days."

29· · · · · · · · · ·I don't know who that is

30· · speaking that, but that is not the import of my

31· · question.

32· · · · · · · · · ·A. Nor do I.

Page 6979·1· · · · · · · · · ·Q. Okay.· And then this

·2· · statement is made:

·3· · · · · · · · · ·"Why weren't we get[ting] any

·4· · · · · · · · · ·answers from Caressant Care when

·5· · · · · · · · · ·he passed away.· Mom and dad

·6· · · · · · · · · ·tried and tried to get answers

·7· · · · · · · · · ·as to what happened and they

·8· · · · · · · · · ·would not tell them anything.

·9· · · · · · · · · ·And they referred them to the

10· · · · · · · · · ·coroner's office and the

11· · · · · · · · · ·coroner's office had no answers.

12· · · · · · · · · ·I was supposed to go away and I

13· · · · · · · · · ·said I would stay home, and they

14· · · · · · · · · ·said no no, Caressant Care says

15· · · · · · · · · ·he's not that sick [and] go

16· · · · · · · · · ·ahead and go.· Well I just

17· · · · · · · · · ·nicely got to where I was going

18· · · · · · · · · ·and got a phone call that he had

19· · · · · · · · · ·passed away.· So like why were.

20· · · · · · · · · ·Sorry, I'm getting emotional.

21· · · · · · · · · ·That's ok [...]"

22· · · · · · · · · ·And this is the questioner

23· · saying, I think, "[...] take your time", am I

24· · right about that?

25· · · · · · · · · ·A. I think so.

26· · · · · · · · · ·Q. "[...] I blame [that] on

27· · · · · · · · · ·Caressant Care.· I just want to

28· · · · · · · · · ·make sure I've got this

29· · · · · · · · · ·straight.· So, your mom and dad

30· · · · · · · · · ·were looking for answers before

31· · · · · · · · · ·and after he passed away [from]

32· · · · · · · · · ·condition?· They called at about

Page 6980·1· · · · · · · · · ·1 o'clock in the morning or

·2· · · · · · · · · ·something and said he passed

·3· · · · · · · · · ·away.· And they tried for, I bet

·4· · · · · · · · · ·they tried for months, to find

·5· · · · · · · · · ·out [...] why he passed away.

·6· · · · · · · · · ·So to this day, we [don't]

·7· · · · · · · · · ·really don't know why he passed

·8· · · · · · · · · ·away."

·9· · · · · · · · · ·And it continues.

10· · · · · · · · · ·And so I have accurately read

11· · what has been recorded here?

12· · · · · · · · · ·A. Pretty much.

13· · · · · · · · · ·Q. Okay.· Did I miss anything?

14· · · · · · · · · ·A. A couple of words here and

15· · there, but they weren't significant.

16· · · · · · · · · ·Q. Okay, thank you.

17· · · · · · · · · ·And so at that moment in time,

18· · when you have a family member in the course of

19· · an inspection, are you allowed to make

20· · referrals to the Coroners Office, to the Chief

21· · Coroner, to a College, to anything like that

22· · where you say, you know, this doesn't form part

23· · of my job; my job is to do this inspection, but

24· · you need to go to this person, this person and

25· · this person for answers on that?

26· · · · · · · · · ·A. I would say we are probably

27· · allowed to.

28· · · · · · · · · ·Q. Yes, okay.· And did you make

29· · any such referral in this instance?

30· · · · · · · · · ·A. No.

31· · · · · · · · · ·MS. FRASER:· Okay.

32· · · · · · · · · ·Madam Commissioner, that

Page 6981·1· · · · · · · · · ·document was marked for

·2· · · · · · · · · ·identification, but it is also a

·3· · · · · · · · · ·source document.· So I don't

·4· · · · · · · · · ·know how you want to deal with

·5· · · · · · · · · ·it.· You'll find it in your

·6· · · · · · · · · ·source documents, but that was

·7· · · · · · · · · ·the document that we had some

·8· · · · · · · · · ·discussion about in the Coroners

·9· · · · · · · · · ·section.

10· · · · · · · · · ·THE COMMISSIONER:· As a

11· · · · · · · · · ·housekeeping matter, I am going

12· · · · · · · · · ·to look to Commission Counsel to

13· · · · · · · · · ·decide on each of the matters

14· · · · · · · · · ·that had -- on each of the

15· · · · · · · · · ·documents that had letter

16· · · · · · · · · ·identification how we want to

17· · · · · · · · · ·handle that.· And if I

18· · · · · · · · · ·understand you correctly, that

19· · · · · · · · · ·is one of those documents,

20· · · · · · · · · ·right?

21· · · · · · · · · ·MS. FRASER:· I think so, but I

22· · · · · · · · · ·actually don't have the exhibit

23· · · · · · · · · ·copy.· Like I can't compare it

24· · · · · · · · · ·to exactly what I have handed up

25· · · · · · · · · ·in this excerpt, Commissioner.

26· · · · · · · · · ·THE COMMISSIONER:· Yes, it is,

27· · · · · · · · · ·on my quick review, it is --

28· · · · · · · · · ·well, it is --

29· · · · · · · · · ·MS. FRASER:· There may be more

30· · · · · · · · · ·or less pages from that

31· · · · · · · · · ·document.

32· · · · · · · · · ·THE COMMISSIONER:· I was just

Page 6982·1· · · · · · · · · ·going to say you have to look at

·2· · · · · · · · · ·the documents, because the

·3· · · · · · · · · ·Exhibit "F", which is the one --

·4· · · · · · · · · ·MS. FRASER:· Commissioner, maybe

·5· · · · · · · · · ·we can sort that out.

·6· · · · · · · · · ·THE COMMISSIONER:· I was just

·7· · · · · · · · · ·going to say, that is exactly

·8· · · · · · · · · ·what I was going to do is at

·9· · · · · · · · · ·some point this week I was going

10· · · · · · · · · ·to invite counsel, Commission

11· · · · · · · · · ·Counsel, to sort out with the

12· · · · · · · · · ·various documents and counsel

13· · · · · · · · · ·how we think it is best to deal

14· · · · · · · · · ·with the exhibit, the lettered

15· · · · · · · · · ·exhibits next before the

16· · · · · · · · · ·conclusion of next week.

17· · · · · · · · · ·MS. FRASER:· Thank you.

18· · · · · · · · · ·THE COMMISSIONER:· Thank you.

19· · · · · · · · · ·THE WITNESS:· Would it be okay

20· · · · · · · · · ·if I said one more thing?

21· · · · · · · · · ·BY MS. FRASER:

22· · · · · · · · · ·Q. I think you are allowed to

23· · give your answer, yes.

24· · · · · · · · · ·A. There was more to that

25· · interview that we haven't spoken to.

26· · · · · · · · · ·Q. Yes.

27· · · · · · · · · ·A. That it seems I would think

28· · is relevant related to your line of

29· · questioning.

30· · · · · · · · · ·Q. Yes?

31· · · · · · · · · ·A. So --

32· · · · · · · · · ·Q. Go ahead.

Page 6983·1· · · · · · · · · ·A. We did tell the family, and I

·2· · am going to read it.

·3· · · · · · · · · ·Q. And we just want to put it up

·4· · on the screen.· So can you give me the page

·5· · number that you are at, please?

·6· · · · · · · · · ·A. It is 44.

·7· · · · · · · · · ·Q. Page 44, okay.· And I think

·8· · you are going to take us to the part that says:

·9· · · · · · · · · ·"You can ask Caressant Care

10· · · · · · · · · ·[and] [...] go through Freedom

11· · · · · · · · · ·of Information [...]"?

12· · · · · · · · · ·A. Yes.

13· · · · · · · · · ·Q. I'm sorry I didn't take you

14· · to that.· That was not intentional.· I was

15· · focussed on the comments and I was interested

16· · in the time.

17· · · · · · · · · ·"Actually, [as] you go see the

18· · · · · · · · · ·crown, they might be able to

19· · · · · · · · · ·direct you as far as the process

20· · · · · · · · · ·for that, [or] [...] the best

21· · · · · · · · · ·way to go about that."

22· · · · · · · · · ·A. Yes, so I think I misspoke

23· · when I said I didn't refer them to anyone,

24· · because it looks like we did.

25· · · · · · · · · ·Q. Yeah, and I didn't mean to

26· · lead you in that direction, if that was not the

27· · case, so thank you for that clarification.

28· · That is important.

29· · · · · · · · · ·You talked about -- and we are

30· · going to leave this document now.

31· · · · · · · · · ·You talked about your approach

32· · in going into an inspection and looking for

Page 6984·1· · compliance?

·2· · · · · · · · · ·A. Yes.

·3· · · · · · · · · ·Q. And we have heard a lot about

·4· · that.· Is that part of the training, that you

·5· · are to go look for compliance?

·6· · · · · · · · · ·A. Yes, we are to look to

·7· · evidence of compliance.

·8· · · · · · · · · ·Q. Okay.· And I know that you

·9· · believe yourself to be resident-focussed and I

10· · know that you understand that the standards are

11· · there to protect residents, and I am wondering

12· · whether you think it is the approach of

13· · inspections would be better served from a more

14· · what I would consider neutral, which is to

15· · identify whether the home has been fulfilling

16· · its legal obligations under the Act?

17· · · · · · · · · ·A. I kind of thought it is the

18· · same thing.

19· · · · · · · · · ·Q. Right.· Well, if it is the

20· · same thing, why would you not go look for

21· · non-compliance?

22· · · · · · · · · ·A. If we can't find evidence to

23· · support compliance, that means there is a good

24· · probability that we have evidence to support

25· · non-compliance.· So they are happening at the

26· · same time.

27· · · · · · · · · ·Q. All right, so I think we just

28· · look at things differently.

29· · · · · · · · · ·You would agree with me that if

30· · people are fulfilling the objects of the Act,

31· · that it should not be difficult for people to

32· · show Inspectors how they have complied?

Page 6985·1· · · · · · · · · ·A. I find myself in a difficult

·2· · position just considering the line of

·3· · questioning from Mr. Golden to your

·4· · questioning.

·5· · · · · · · · · ·Q. Oh, okay, so I am not

·6· · speaking about where you come in and everybody

·7· · is traumatized and it is the equivalent of

·8· · somebody basically shooting up a neighbourhood

·9· · and everybody having to pick up the pieces. I

10· · understand that, having been through a shooting

11· · in my neighbourhood in the last two weeks, that

12· · that is a difficult situation.

13· · · · · · · · · ·But in the normal course of

14· · things, you go into a home, you are there, and

15· · that if everybody is doing their job, that

16· · there should be evidence of compliance?

17· · · · · · · · · ·A. Yes.

18· · · · · · · · · ·Q. Okay.· These circumstances

19· · were unique and different, right?

20· · · · · · · · · ·A. Yes.

21· · · · · · · · · ·Q. And there was no handbook for

22· · them?

23· · · · · · · · · ·A. There was not.

24· · · · · · · · · ·Q. And you went in with a

25· · critical mind to say what -- basically to try

26· · to answer the question that everybody in the

27· · public was looking for, which is how did this

28· · happen, right?

29· · · · · · · · · ·A. No, I went in looking for

30· · evidence of compliance with the legislation.

31· · · · · · · · · ·Q. Okay.· I want to -- I want to

32· · talk to you and just follow up on a couple of

Page 6986·1· · questions that Mr. Van Kralingen asked you

·2· · about the value of the employee file, Elizabeth

·3· · Wettlaufer's employment file.

·4· · · · · · · · · ·A. Yes.

·5· · · · · · · · · ·Q. Okay, and you recall those

·6· · questions.· I want to say my reading of your

·7· · inspection on this issue and the value of the

·8· · employee file is that it had a number of

·9· · different values for you, and I am just going

10· · to take you through three of them, okay.

11· · · · · · · · · ·A. Okay.

12· · · · · · · · · ·Q. So the first thing is that

13· · when you asked for the employee file, you were

14· · able to find a number of complaints in that

15· · file that were not elsewhere in a general

16· · complaints file for the home, right?

17· · · · · · · · · ·A. Yes.

18· · · · · · · · · ·Q. Okay, and you needed -- you

19· · asked for a complaint file for the home but

20· · there was no complaint file for the period of

21· · 2010 to 2014; am I right?

22· · · · · · · · · ·A. Yes.

23· · · · · · · · · ·Q. Okay.· So in the absence of a

24· · complaint file in the home, you went into the

25· · employee file -- and it may not necessarily be

26· · in this order, okay.

27· · · · · · · · · ·A. Not in that order, no.

28· · · · · · · · · ·Q. But by comparing those two

29· · things, you were able to ascertain that there

30· · were complaints that had been made about

31· · Elizabeth Wettlaufer that would not have been

32· · located if you had just gone to a complaints

Page 6987·1· · file because there was no complaints file?

·2· · · · · · · · · ·A. In that situation, there was

·3· · no complaints file.

·4· · · · · · · · · ·Q. Right, okay.· If you were

·5· · doing it in another home and looking at an

·6· · employee file, you might be able to correlate

·7· · what is in an employee file with what is in the

·8· · complaints file, right?

·9· · · · · · · · · ·A. Yes.

10· · · · · · · · · ·Q. And then say, okay, well, it

11· · is in the employment file; why is it not in the

12· · complaints file, right?

13· · · · · · · · · ·A. Yes.

14· · · · · · · · · ·Q. Okay.· You were able to

15· · discern from that complaints file that there

16· · were times when people ought to have made

17· · reports to the Director about a suspected abuse

18· · and neglect that were not made, right?

19· · · · · · · · · ·A. No, it was from the employee

20· · file.

21· · · · · · · · · ·Q. Right, that was another value

22· · of this particular employee file, right?

23· · · · · · · · · ·A. The employee file review,

24· · when we noted the complaints that were in

25· · there, helped to form questioning.

26· · · · · · · · · ·Q. Okay.

27· · · · · · · · · ·A. And we needed to further

28· · inspect on that to see if there was

29· · non-compliance related to that.· It posed

30· · questions for us.· I would never conclude only

31· · on an employee file review that that was

32· · non-compliance.

Page 6988·1· · · · · · · · · ·Q. Yes, okay.· If we could turn

·2· · to page 19 of it is tab "J" of your affidavit.

·3· · You have been taken to this report many times.

·4· · 43372.

·5· · · · · · · · · ·And just while that is coming

·6· · up, do you ever, in the course of going into a

·7· · home in terms of communicating with residents,

·8· · do you have assistive devices that would help

·9· · you with communication like a Pocket-Talker?

10· · · · · · · · · ·A. I don't.

11· · · · · · · · · ·Q. No?

12· · · · · · · · · ·A. But we can always call an

13· · interpreter.

14· · · · · · · · · ·Q. Okay, do you ever have a --

15· · what about for somebody who is just hard of

16· · hearing and doesn't have their hearing aids

17· · because they have gone missing, as is sometimes

18· · the case, I understand?· Okay --

19· · · · · · · · · ·A. I hesitate.· There are --

20· · like we -- we can write things down.

21· · · · · · · · · ·Q. Yes.

22· · · · · · · · · ·A. And there have been times

23· · where we have just talked really, really loud,

24· · and you just try your best to maintain privacy

25· · for that resident, because you are essentially

26· · yelling and you don't want anybody else to

27· · overhear and you want them to have privacy, but

28· · they can hear you when you speak really loudly.

29· · · · · · · · · ·Q. Right, so --

30· · · · · · · · · ·A. And you -- I might gather

31· · information about are they deaf in both ears or

32· · are they only deaf in one ear, so then I know

Page 6989·1· · to go to that side.

·2· · · · · · · · · ·Q. That is fine.· And what about

·3· · for clients or residents who have aphasia, do

·4· · you ever employ the services of a

·5· · speech-language pathologist to help you with

·6· · that discussion?

·7· · · · · · · · · ·A. I have not.

·8· · · · · · · · · ·Q. Okay.

·9· · · · · · · · · ·A. But we have other means of

10· · being able to communicate with people.

11· · · · · · · · · ·Q. Like a communication board?

12· · Do you ever use those?

13· · · · · · · · · ·A. Sometimes they have

14· · communication boards.· Sometimes they are able

15· · to answer with yes or no's or nodding or

16· · shaking their head.

17· · · · · · · · · ·Q. Okay.· I think this is

18· · document 43372 on the screen.· If we could

19· · please go to page, actually, 9.· Thank you,

20· · Laura.

21· · · · · · · · · ·And you have gone through these

22· · findings both -- if you could go a little

23· · further up on the page, I am interested in the

24· · paragraph starting "In an interview with the

25· · Medical Director [...]"

26· · · · · · · · · ·And going down, so this is the

27· · finding where you made where the licensee

28· · failed to have the interdisciplinary team.· You

29· · discuss the Medical Director, and that is Dr.

30· · Reddick, right?

31· · · · · · · · · ·A. Yes.

32· · · · · · · · · ·Q. Okay, and that he:

Page 6990·1· · · · · · · · · ·"[...] had been providing

·2· · · · · · · · · ·service to the home for over 40

·3· · · · · · · · · ·years and had not participated

·4· · · · · · · · · ·in any Medication Management

·5· · · · · · · · · ·System program evaluations",

·6· · · · · · · · · ·right?

·7· · · · · · · · · ·I have read that correctly?

·8· · · · · · · · · ·A. Yes.

·9· · · · · · · · · ·Q. Did you have an appreciation

10· · from Dr. Reddick that he understood that by

11· · being Medical Director, that he was fulfilling

12· · a statutory role under the legislation?

13· · · · · · · · · ·A. I did not get that

14· · impression.

15· · · · · · · · · ·Q. All right.· Was your

16· · impression that he did not understand what his

17· · statutory obligations were?

18· · · · · · · · · ·A. Yes.

19· · · · · · · · · ·Q. Okay.· And just going down

20· · then, under the -- a little further down on the

21· · page, you talk about:

22· · · · · · · · · ·"The home was not able to

23· · · · · · · · · ·produce any documentation of

24· · · · · · · · · ·quarterly evaluations of the

25· · · · · · · · · ·medication management system, or

26· · · · · · · · · ·changes that were identified or

27· · · · · · · · · ·implemented as a result of a

28· · · · · · · · · ·quarterly evaluation."

29· · · · · · · · · ·And then you conclude:

30· · · · · · · · · ·"The severity of this

31· · · · · · · · · ·non-compliance is minimal risk

32· · · · · · · · · ·and the scope is widespread."

Page 6991·1· · · · · · · · · ·And I just was really struck by

·2· · that statement given the number of people who

·3· · had died.· Do you not think it is an absurd

·4· · result to say that "The severity of [the]

·5· · non-compliance is minimal risk [...]"?

·6· · · · · · · · · ·A. I am not going to say that my

·7· · finding was absurd.

·8· · · · · · · · · ·Q. It may be that your judgment

·9· · matrix took you to that finding.

10· · · · · · · · · ·A. Yes.

11· · · · · · · · · ·Q. Okay, but given that all of

12· · these -- that there had been seven deaths in

13· · this home at the time that you are conducting

14· · this inspection, it would seem very odd to say

15· · that the severity of the non-compliance is

16· · minimal risk; do you not agree?

17· · · · · · · · · ·A. I can't equate the deaths to

18· · the medication -- the review of the medication

19· · management system.

20· · · · · · · · · ·MS. FRASER:· Okay.

21· · · · · · · · · ·Commissioner, I am cognizant of

22· · · · · · · · · ·the time, and I have questions

23· · · · · · · · · ·and I don't have a lot of time

24· · · · · · · · · ·in my allocation, but I will be

25· · · · · · · · · ·another few minutes, okay.

26· · · · · · · · · ·THE COMMISSIONER:· If you feel

27· · · · · · · · · ·that you can make better use of

28· · · · · · · · · ·your time if we break, then we

29· · · · · · · · · ·can do that.· If you want to

30· · · · · · · · · ·finish now, you go ahead, Ms.

31· · · · · · · · · ·Fraser.

32· · · · · · · · · ·MS. FRASER:· My motor is

Page 6992·1· · · · · · · · · ·running.· I will keep it going.

·2· · · · · · · · · ·THE COMMISSIONER:· Okay.

·3· · · · · · · · · ·BY MS. FRASER:

·4· · · · · · · · · ·Q. All right.· I want to ask you

·5· · a little bit about DW, and so if we could go to

·6· · page 22 of that same document, please.

·7· · · · · · · · · ·And so I know that from what you

·8· · have told us that sometimes information shows

·9· · up in different parts of these reports, so this

10· · part of the report, as I understand, deals

11· · with -- and I am at the bottom of what is page

12· · 22.

13· · · · · · · · · ·Yes, here we go.

14· · · · · · · · · ·So you are discussing this

15· · critical incident involving DW and:

16· · · · · · · · · ·"The statements of 'do you need

17· · · · · · · · · ·a Haldol injection' and 'do you

18· · · · · · · · · ·need a psychiatric evaluation'

19· · · · · · · · · ·from the registered nurse in the

20· · · · · · · · · ·role of supervisor on the unit

21· · · · · · · · · ·to a resident can be considered

22· · · · · · · · · ·verbal communication of a

23· · · · · · · · · ·threatening or intimidating

24· · · · · · · · · ·nature."

25· · · · · · · · · ·And you have discussed all of

26· · that.

27· · · · · · · · · ·But I understand, just if we

28· · look further down starting at "B", that what

29· · you then did is in addition to having that, you

30· · actually looked to DW's medication records to

31· · see what transpired after those statements were

32· · made; is that right?

Page 6993·1· · · · · · · · · ·A. Sorry?

·2· · · · · · · · · ·Q. So just if you can read, read

·3· · to yourself the part starting at "B" on the

·4· · bottom of that page of page 22, starting with:

·5· · · · · · · · · ·"The employee records were

·6· · · · · · · · · ·reviewed [...].· Email

·7· · · · · · · · · ·communication [...] and meeting

·8· · · · · · · · · ·documentation [...]"

·9· · · · · · · · · ·And then -- oh, sorry, actually,

10· · I'm taking you to the wrong paragraph.

11· · · · · · · · · ·But what was said also was:

12· · · · · · · · · ·"'Look, you are sick.· You have

13· · · · · · · · · ·Alzheimer's and you are confused

14· · · · · · · · · ·[and] you do not know what you

15· · · · · · · · · ·are talking about.· You cannot

16· · · · · · · · · ·remember and you need to trust

17· · · · · · · · · ·the staff'."

18· · · · · · · · · ·And the:

19· · · · · · · · · ·"Resident replied 'I'm not

20· · · · · · · · · ·sick'."

21· · · · · · · · · ·A. That is a different resident.

22· · That is not DW.

23· · · · · · · · · ·Q. Ah, I see, okay.· And that

24· · particular resident then, you went to that

25· · resident's health records and looked at what

26· · came after that, right?

27· · · · · · · · · ·A. I didn't.

28· · · · · · · · · ·Q. Someone did?

29· · · · · · · · · ·A. Marian MacDonald did.

30· · · · · · · · · ·Q. Okay, and what she

31· · documented, what was documented and what ends

32· · up being documented is that Trazodone was

Page 6994·1· · administered?

·2· · · · · · · · · ·A. Trazodone.

·3· · · · · · · · · ·Q. Right, and what kind of

·4· · medication is that?

·5· · · · · · · · · ·A. I believe it is an

·6· · antidepressant.

·7· · · · · · · · · ·Q. Okay.· And Risperidone, do

·8· · you know what that is?

·9· · · · · · · · · ·A. I believe it is an

10· · antipsychotic.

11· · · · · · · · · ·Q. Right.· And Haldol?

12· · · · · · · · · ·A. Antipsychotic.

13· · · · · · · · · ·Q. Okay.· So after this

14· · interaction with staff, then three medications

15· · which were given, and the word in the paragraph

16· · above that indicates they were chemical

17· · restraints?

18· · · · · · · · · ·A. It looks that way.

19· · · · · · · · · ·Q. Okay, are chemical restraints

20· · permitted in long-term care?

21· · · · · · · · · ·A. Yes.

22· · · · · · · · · ·Q. In what circumstances?

23· · · · · · · · · ·A. I would have to refer to the

24· · legislation.

25· · · · · · · · · ·Q. Okay.· I would say that if

26· · this assists you, in circumstances where there

27· · is a danger to self or others?

28· · · · · · · · · ·A. I would have to refer to the

29· · legislation.

30· · · · · · · · · ·Q. Okay, thank you.

31· · · · · · · · · ·You said in your evidence --

32· · well, you and I can both agree that one thing

Page 6995·1· · we share in common is for something like this

·2· · never to happen again, right?

·3· · · · · · · · · ·A. We can on this.

·4· · · · · · · · · ·Q. Okay.· And I understand how

·5· · shaken people working in a profession that they

·6· · love would be by this happening.

·7· · · · · · · · · ·But I am going to suggest to you

·8· · that we have known for decades that nurses are

·9· · capable of abuse and neglect of residents in

10· · long-term care; do you agree?

11· · · · · · · · · ·A. I take issue with your only

12· · referring to nurses.

13· · · · · · · · · ·Q. We are dealing with a nurse

14· · in the course of this Inquiry, but you can

15· · agree that people, trusted, helping and --

16· · trusted, helping and health professionals have

17· · been capable of abuse in long-term care, and

18· · that is something that we have known about for

19· · decades; do you agree?

20· · · · · · · · · ·A. They are capable.

21· · · · · · · · · ·Q. Yes, and we have known that?

22· · · · · · · · · ·A. Okay.

23· · · · · · · · · ·Q. You don't understand that

24· · part of the reason that we have standards is

25· · because people didn't fulfil their obligations

26· · to residents in long-term care?

27· · · · · · · · · ·A. No, I didn't say that.

28· · · · · · · · · ·Q. Okay.· In fact, that is one

29· · of the reasons we have standards, is because

30· · people can't be trusted to rely on their own

31· · judgment?

32· · · · · · · · · ·A. I believe I said yesterday

Page 6996·1· · the reason for a lot of these, the things in

·2· · here, is because something bad has happened at

·3· · some point in time in history that human beings

·4· · have been not very nice to one another.

·5· · · · · · · · · ·And what we did in response to

·6· · try to make sure that doesn't happen again is

·7· · create legislation and laws to try to

·8· · regulate --

·9· · · · · · · · · ·Q. Right.

10· · · · · · · · · ·A. -- wherever to try to make

11· · sure that doesn't happen again.

12· · · · · · · · · ·Q. And we were supposed to be in

13· · an environment of zero tolerance for abuse and

14· · neglect, right?

15· · · · · · · · · ·A. Yes.

16· · · · · · · · · ·Q. And where nurses don't report

17· · and other health professionals don't report

18· · where there is abuse and neglect, that can't be

19· · seen as zero tolerance; do you agree?

20· · · · · · · · · ·A. I look at reporting and the

21· · actual abuse as two separate things.

22· · · · · · · · · ·Q. Okay.· One way of ensuring

23· · that abuse and neglect is not tolerated is by

24· · letting the Ministry know that there has been

25· · abuse and neglect so that the Ministry can step

26· · in and do an inspection; do you agree?

27· · · · · · · · · ·A. Yes, but that is barring the

28· · section 23 where the first thing -- not the

29· · first thing, but concurrently the home has to

30· · initiate an immediate investigation.

31· · · · · · · · · ·Q. Yes, and where that doesn't

32· · happen, somebody who is inclined to harm

Page 6997·1· · residents can operate with free licence to harm

·2· · them if nothing ever gets done; do you agree?

·3· · · · · · · · · ·A. That is pretty strong.

·4· · · · · · · · · ·Q. Well, if there is no

·5· · accountability in long-term care, do you not

·6· · agree that somebody like Elizabeth Wettlaufer

·7· · can flourish in an environment where there is

·8· · zero accountability?

·9· · · · · · · · · ·A. It is just so strong, but

10· · yes.

11· · · · · · · · · ·MS. FRASER:· Thank you.· I have

12· · · · · · · · · ·no other questions,

13· · · · · · · · · ·Commissioner.

14· · · · · · · · · ·THE COMMISSIONER:· Thank you.

15· · · · · · · · · ·MS. STEPHENS:· I understand --

16· · · · · · · · · ·oh, so ONA has some questions as

17· · · · · · · · · ·well?

18· · · · · · · · · ·MS. BUTT:· I have maybe five

19· · · · · · · · · ·minutes at most.

20· · · · · · · · · ·MS. STEPHENS:· Okay, and the

21· · · · · · · · · ·Ministry does have some

22· · · · · · · · · ·re-examination.· So I think,

23· · · · · · · · · ·given that it is now 10 after

24· · · · · · · · · ·1:00, and the Ministry probably

25· · · · · · · · · ·has more than five minutes, we

26· · · · · · · · · ·should probably break for lunch.

27· · · · · · · · · ·THE COMMISSIONER:· Can we just

28· · · · · · · · · ·hear ONA?· I think it would be

29· · · · · · · · · ·better.

30· · · · · · · · · ·MS. STEPHENS:· Okay.

31· · · · · · · · · ·THE COMMISSIONER:· Because it

32· · · · · · · · · ·may affect the re-examination,

Page 6998·1· · · · · · · · · ·and that gives him the chance

·2· · · · · · · · · ·over lunch to pull things

·3· · · · · · · · · ·together.· So let's hear from

·4· · · · · · · · · ·ONA.

·5· · · · · · · · · ·MS. STEPHENS:· Okay, thank you.

·6· · · · · · · · · ·CROSS-EXAMINATION BY MS. BUTT:

·7· · · · · · · · · ·Q. Good afternoon.· I'm Nicole

·8· · Butt, and I'm Counsel for the Ontario Nurses

·9· · Association.· And I just have a few questions

10· · for you.

11· · · · · · · · · ·You were asked some questions

12· · earlier by Mr. Scott about your role as an

13· · Inspector, especially as it relates to staffing

14· · levels.· And so I just wanted to be clear.

15· · Your role is to determine compliance with the

16· · Act, and with respect to Registered Nurse

17· · staffing, that is the minimum floor set in

18· · section 8?

19· · · · · · · · · ·A. Yes.

20· · · · · · · · · ·Q. So to make sure that there is

21· · one Registered Nurse in the building at all

22· · times?

23· · · · · · · · · ·A. Yes.

24· · · · · · · · · ·Q. Subject to any exception in

25· · the emergency provisions of the regulations?

26· · · · · · · · · ·A. Yes.

27· · · · · · · · · ·Q. And we have heard evidence

28· · that there is various sizes of homes, so Telfer

29· · Place has 45 beds, Meadow Park has 126,

30· · Caressant Care Woodstock had 163.· And there is

31· · some homes in the province that are much

32· · larger, so there is one in Thunder Bay, for

Page 6999·1· · example, that has 563 beds, so --

·2· · · · · · · · · ·A. I didn't know that.

·3· · · · · · · · · ·Q. Okay, it is fairly new.

·4· · · · · · · · · ·Despite the size of the home,

·5· · your role as an Inspector doesn't change.· It

·6· · is always just to make sure that there is the

·7· · one Registered Nurse in the home at all times?

·8· · · · · · · · · ·A. That's correct.

·9· · · · · · · · · ·Q. And you have testified that

10· · your role is to look for compliance, so if you

11· · confirm compliance with that section 8 minimum

12· · floor, do you look to see how it is complied

13· · with?

14· · · · · · · · · ·A. In what way?

15· · · · · · · · · ·Q. So for example, we have heard

16· · evidence from Caressant Care that there was one

17· · nurse who worked many, many doubles and even

18· · triples.· There was other evidence of nurses on

19· · how busy they are, that they stay late,

20· · sometimes they stay hours to complete their

21· · documentation.

22· · · · · · · · · ·Are you as an Inspector able to

23· · look at that to see how they complied with

24· · section 8, or is it just compliance?

25· · · · · · · · · ·A. It is compliance.· However,

26· · if any of those other things are having an

27· · impact on resident care which led to other

28· · non-compliance in the legislation, I would look

29· · at that under the other area of legislation and

30· · issue it in that area.

31· · · · · · · · · ·Q. If you could bring up 71420.

32· · · · · · · · · ·A. Can you tell me where that

Page 7000·1· · is?· I don't --

·2· · · · · · · · · ·Q. Oh, sorry, and I wasn't

·3· · anticipating this, so it is the transcript of

·4· · Ms. Wettlaufer's -- it is Exhibit 5 of her

·5· · interview with Commission Counsel, page 59.

·6· · And I am just going to read some --

·7· · · · · · · · · ·A. I have no idea where that is,

·8· · or I don't --

·9· · · · · · · · · ·THE COMMISSIONER:· Madam Clerk,

10· · · · · · · · · ·I have given you an extra copy

11· · · · · · · · · ·of that, so if you -- that is

12· · · · · · · · · ·the transcript.

13· · · · · · · · · ·THE COURT CLERK:· I have to find

14· · · · · · · · · ·it, Commissioner, in our exhibit

15· · · · · · · · · ·pile to give her a hard copy.

16· · · · · · · · · ·THE COMMISSIONER:· All right.

17· · · · · · · · · ·MS. STEPHENS:· Rhonda, it will

18· · · · · · · · · ·be on the screen, if that --

19· · · · · · · · · ·there is a screen in front of

20· · · · · · · · · ·you.

21· · · · · · · · · ·THE WITNESS:· I'll do my best.

22· · · · · · · · · ·It just is not conducive to

23· · · · · · · · · ·progressive lenses.

24· · · · · · · · · ·BY MS. BUTT:

25· · · · · · · · · ·Q. Okay.· So Ms. Wettlaufer was

26· · interviewed by Commission Counsel prior to

27· · this, and on page 59 she is talking about

28· · working at Caressant Care Woodstock.· And I'm

29· · just trying to get to the right reference.

30· · · · · · · · · ·And so starting on line 4, she

31· · says:

32· · · · · · · · · ·"And then when I was under

Page 7001·1· · · · · · · · · ·stress at Caressant Care the

·2· · · · · · · · · ·thoughts started coming, you

·3· · · · · · · · · ·know, maybe I should kill

·4· · · · · · · · · ·somebody."

·5· · · · · · · · · ·And then they go on and they ask

·6· · her about that you have had these thoughts

·7· · before, "but I never did anything about it, not

·8· · until I got to Caressant Care".

·9· · · · · · · · · ·And then she goes on at line 17

10· · again to talk about the huge stress, the huge

11· · workload, and then further on she talks about

12· · working double shifts.

13· · · · · · · · · ·And I guess my question to

14· · you -- and this was just for context to show

15· · that, you know, she has identified workload and

16· · stress.· As an Inspector, do you have the power

17· · to issue any orders if staff are telling you

18· · that they are stressed and their workload is

19· · very high?

20· · · · · · · · · ·A. If it is having a negative

21· · impact on resident care that is -- and there is

22· · legislation that speaks to that, then I would

23· · do that in that place.

24· · · · · · · · · ·Q. Can you give us an example?

25· · · · · · · · · ·A. If there were medication

26· · incidents, then I would issue under potentially

27· · 131 or 135, but that is dependent on finding

28· · the evidence to support that non-compliance.

29· · · · · · · · · ·Q. So could you --

30· · · · · · · · · ·A. The reason for that, that

31· · they are stressed, is not something I have

32· · legislation that speaks to.· I would need to

Page 7002·1· · look for areas that the legislation -- I can

·2· · only act within the legislation.

·3· · · · · · · · · ·Q. And that was my question.

·4· · · · · · · · · ·One final question.· Often,

·5· · putting aside the RQIs, when you are looking at

·6· · compliance with section 8, do you need a

·7· · trigger to go in and look at that?· For

·8· · example, there is no mandatory reporting of a

·9· · violation of section 8 to the Ministry?

10· · · · · · · · · ·A. No, there is not.

11· · · · · · · · · ·MS. BUTT:· Okay, thank you.

12· · · · · · · · · ·Those are all my questions.

13· · · · · · · · · ·THE COMMISSIONER:· Thank you.

14· · · · · · · · · ·All right, so why don't, unless

15· · · · · · · · · ·there is something else, let's

16· · · · · · · · · ·take the lunch recess now, and

17· · · · · · · · · ·then when we come back, we'll

18· · · · · · · · · ·turn to Mr. Kloeze.

19· · · · · · · · · ·Thank you.

20· · · · · · · · · ·-- RECESSED AT 1:18 P.M.

21· · · · · · · · · ·-- RESUMED AT 2:35 P.M.

22· · · · · · · · · ·MR. KLOEZE:· Good afternoon,

23· · · · · · · · · ·Commissioner.

24· · · · · · · · · ·THE COMMISSIONER:· Good

25· · · · · · · · · ·afternoon.

26· · · · · · · · · ·RE-EXAMINATION BY MR. KLOEZE:

27· · · · · · · · · ·Q. Good afternoon, Rhonda.

28· · · · · · · · · ·A. Good afternoon.

29· · · · · · · · · ·Q. We're almost done.

30· · · · · · · · · ·A. Yes.

31· · · · · · · · · ·Q. I just have a few questions

32· · for you actually.· It won't take long.

Page 7003·1· · · · · · · · · ·Mr. Van Kralingen asked you

·2· · earlier today whether or not you thought it was

·3· · a good idea or something to explore as to

·4· · whether there should be reporting to the

·5· · director of the branch all incidents of stolen

·6· · or missing narcotics.· Do you remember him

·7· · asking you that question?

·8· · · · · · · · · ·A. I think so.

·9· · · · · · · · · ·Q. And you said, I think fairly,

10· · that, you know, it would be a best practice to

11· · look at -- look further into the sharing of

12· · information in that regard?

13· · · · · · · · · ·A. Yes.

14· · · · · · · · · ·Q. Now, the one question I have

15· · is whether or not it's the responsibility of

16· · the director of the inspections branch to

17· · determine whether or not a theft occurred in a

18· · home if there is a case of missing narcotics

19· · and also to determine who committed the theft?

20· · · · · · · · · ·A. In my knowledge, it is not.

21· · · · · · · · · ·Q. And whose responsibility is

22· · that?

23· · · · · · · · · ·A. The home and the police.

24· · · · · · · · · ·Q. Thank you.

25· · · · · · · · · ·Another question

26· · Mr. Van Kralingen brought you to is at

27· · paragraph 25 of your Affidavit.· And you can

28· · turn it up.· And it involves the timelines that

29· · the London service area office typically has to

30· · complete inspections.

31· · · · · · · · · ·Do you recall that information

32· · for an immediate inspection -- or this is

Page 7004·1· · actually the timelines to get into the home, as

·2· · I understand it; is that correct?

·3· · · · · · · · · ·A. Yes.

·4· · · · · · · · · ·Q. So this is at paragraph 25.

·5· · For a level 4, it's an immediate visit to the

·6· · home; level 3 plus, 30 business days; level 3,

·7· · 60 business days; and thereon.

·8· · · · · · · · · ·And the other day, you said --

·9· · your evidence was that it was a manpower issue

10· · that made it difficult to meet those timelines

11· · at the London service area office?

12· · · · · · · · · ·A. Yes.

13· · · · · · · · · ·Q. Are you aware whether or not

14· · these timelines that are set out here at

15· · paragraph 25 -- are you aware whether these are

16· · set out in the act or the regulations, or is it

17· · a policy issue, a policy matter to meet those

18· · timelines?

19· · · · · · · · · ·A. I believe it's a policy

20· · issue.

21· · · · · · · · · ·Q. Are you aware either way?

22· · · · · · · · · ·A. No.

23· · · · · · · · · ·Q. Okay.· That's fine.

24· · Thank you.

25· · · · · · · · · ·Mr. Scott asked you whether or

26· · not you, as an inspector, have the authority to

27· · drop into a home after-hours, say, at midnight

28· · or in the early hours of the morning just to

29· · look around.· And I think you said in answer to

30· · Mr. Scott that you don't believe you have the

31· · authority just to look around.

32· · · · · · · · · ·My question is if you felt that

Page 7005·1· · a night visit or an after-hours visit was

·2· · required for the purposes of an inspection that

·3· · you're conducting, do you feel that you, as an

·4· · inspector -- that you have the authority to

·5· · enter a home at night?

·6· · · · · · · · · ·A. Yes.

·7· · · · · · · · · ·Q. Mr. Golden asked you a few

·8· · questions first about the medication management

·9· · system program evaluation and the written

10· · notification you made in your EW inspection at

11· · CCW.· Do you remember those questions?

12· · · · · · · · · ·A. Yes.

13· · · · · · · · · ·Q. And it might be best.· Do you

14· · have in front of you a single page which is

15· · Exhibit 19?

16· · · · · · · · · ·A. Yes.

17· · · · · · · · · ·Q. That's it?· Okay.

18· · · · · · · · · ·MR. KLOEZE:· What I propose to

19· · · · · · · · · ·do, Commissioner, we have a

20· · · · · · · · · ·couple of other samples of this

21· · · · · · · · · ·program evaluation from

22· · · · · · · · · ·subsequent years.

23· · · · · · · · · · · They're not entered as

24· · · · · · · · · ·exhibits, and I was hoping to do

25· · · · · · · · · ·that now so that I could show

26· · · · · · · · · ·the witness these other examples

27· · · · · · · · · ·of the program evaluation. I

28· · · · · · · · · ·have copies.

29· · · · · · · · · · · They're three separate

30· · · · · · · · · ·documents.· They're the three

31· · · · · · · · · ·succeeding years.· They're three

32· · · · · · · · · ·separate documents with three

Page 7006·1· · · · · · · · · ·separate doc ID numbers.

·2· · · · · · · · · ·THE COMMISSIONER:· So they're in

·3· · · · · · · · · ·the database?

·4· · · · · · · · · ·MR. KLOEZE:· They're in the

·5· · · · · · · · · ·database.

·6· · · · · · · · · ·THE COMMISSIONER:· And they're

·7· · · · · · · · · ·in the Overview Report?

·8· · · · · · · · · ·MR. KLOEZE:· They're not in the

·9· · · · · · · · · ·Overview Report.

10· · · · · · · · · ·THE COMMISSIONER:· And have you

11· · · · · · · · · ·canvassed this line of

12· · · · · · · · · ·questioning with your

13· · · · · · · · · ·colleagues?

14· · · · · · · · · ·MR. KLOEZE:· I have given notice

15· · · · · · · · · ·of these documents a couple of

16· · · · · · · · · ·nights ago that this was an area

17· · · · · · · · · ·in case this issue came up, so I

18· · · · · · · · · ·did give notice of these

19· · · · · · · · · ·documents.

20· · · · · · · · · ·THE COMMISSIONER:· Okay.

21· · · · · · · · · ·MR. GOLDEN:· Was this in the

22· · · · · · · · · ·witness notice, the notice of

23· · · · · · · · · ·documents for the witness?

24· · · · · · · · · ·MR. KLOEZE:· Yes, the one for --

25· · · · · · · · · ·a couple of nights ago when we

26· · · · · · · · · ·sent the witness notice of

27· · · · · · · · · ·documents.· They're three

28· · · · · · · · · ·additional medication management

29· · · · · · · · · ·system program evaluations.

30· · · · · · · · · · · And I think it would be

31· · · · · · · · · ·useful for the witness to see

32· · · · · · · · · ·these because they are referred

Page 7007·1· · · · · · · · · ·to in her inspection report as

·2· · · · · · · · · ·evidence of noncompliance in

·3· · · · · · · · · ·support of the written

·4· · · · · · · · · ·notification or the finding of

·5· · · · · · · · · ·noncompliance that she made.

·6· · · · · · · · · ·THE COMMISSIONER:· Okay.· You

·7· · · · · · · · · ·know what I'm going to do?· You

·8· · · · · · · · · ·don't have copies for the other

·9· · · · · · · · · ·participants, do you?

10· · · · · · · · · ·MR. KLOEZE:· Not here with me.

11· · · · · · · · · ·I have copies to hand up.

12· · · · · · · · · ·THE COMMISSIONER:· All right.

13· · · · · · · · · ·I'm going to recess for five

14· · · · · · · · · ·minutes.· I think you need to

15· · · · · · · · · ·just show them to the other

16· · · · · · · · · ·participants, and we'll see if

17· · · · · · · · · ·there's any issue, and there may

18· · · · · · · · · ·not be, but if there is, it's

19· · · · · · · · · ·going to be impossible for me to

20· · · · · · · · · ·rule on it without them seeing

21· · · · · · · · · ·the documents as this point.· So

22· · · · · · · · · ·we'll take a five --

23· · · · · · · · · ·MR. KLOEZE:· That's fine. I

24· · · · · · · · · ·just wanted to alert you.· The

25· · · · · · · · · ·other document --

26· · · · · · · · · ·THE COMMISSIONER:· Yes.

27· · · · · · · · · ·MR. KLOEZE:· -- that I intend to

28· · · · · · · · · ·hand up to Ms. Kukoly -- it was

29· · · · · · · · · ·mentioned by Mr. Golden as

30· · · · · · · · · ·well -- were the notes of her

31· · · · · · · · · ·interview with Sandra Fluttert.

32· · · · · · · · · · · Mr. Golden asked her some

Page 7008·1· · · · · · · · · ·questions about her interview

·2· · · · · · · · · ·with Sandra Fluttert.· We found

·3· · · · · · · · · ·notes of that interview or

·4· · · · · · · · · ·Ms. Kukoly's transcription of

·5· · · · · · · · · ·that interview, and I'd like to

·6· · · · · · · · · ·have the witness see that as

·7· · · · · · · · · ·well and enter it as an exhibit.

·8· · · · · · · · · ·THE COMMISSIONER:· Okay.· So

·9· · · · · · · · · ·maybe we'll take a ten-minute

10· · · · · · · · · ·recess.

11· · · · · · · · · · · Ms. Stephens, I think you

12· · · · · · · · · ·have access to that jury room;

13· · · · · · · · · ·right?

14· · · · · · · · · ·MS. STEPHENS:· Yes.· Yes, we do.

15· · · · · · · · · ·THE COMMISSIONER:· So if you

16· · · · · · · · · ·need that, use that, and if you

17· · · · · · · · · ·need extra time, you'll have the

18· · · · · · · · · ·CSO tell me.· I'll just stay

19· · · · · · · · · ·nearby.

20· · · · · · · · · · · If it's a tempest in a teapot

21· · · · · · · · · ·kind of thing and it just blows

22· · · · · · · · · ·over, we'll come right back in.

23· · · · · · · · · ·If you need a few minutes to

24· · · · · · · · · ·think about strategies for

25· · · · · · · · · ·handling it, then I'll leave you

26· · · · · · · · · ·that time.

27· · · · · · · · · ·MS. STEPHENS:· Excellent.

28· · · · · · · · · ·THE REGISTRAR:· This Public

29· · · · · · · · · ·Inquiry is on a ten-minute

30· · · · · · · · · ·recess.

31· · · · · · · · · ·-- RECESSED AT 2:42 P.M. --

32· · · · · · · · · ·-- RESUMED AT 2:46 P.M. --

Page 7009·1· · · · · · · · · ·MR. KLOEZE:· Thank you,

·2· · · · · · · · · ·Commissioner.· I apologize. I

·3· · · · · · · · · ·should have cleared up the

·4· · · · · · · · · ·matter of these documents at the

·5· · · · · · · · · ·lunch break.· I apologize.

·6· · · · · · · · · ·THE COMMISSIONER:· Not at all.

·7· · · · · · · · · ·Thank you.· So everybody is

·8· · · · · · · · · ·content that the documents get

·9· · · · · · · · · ·admitted?

10· · · · · · · · · ·MR. KLOEZE:· Yes.

11· · · · · · · · · ·THE COMMISSIONER:· Thank you.

12· · · · · · · · · ·MR. KLOEZE:· So I've got three

13· · · · · · · · · ·sets of three documents each.

14· · · · · · · · · ·THE COMMISSIONER:· Thank you.

15· · · · · · · · · ·Excellent.

16· · · · · · · · · ·BY MR. KLOEZE:

17· · · · · · · · · ·Q. Rhonda, my suggestion is we

18· · look at these three documents in conjunction

19· · with the one you already had in front of you,

20· · which was Exhibit 19.

21· · · · · · · · · ·A. Okay.

22· · · · · · · · · ·Q. These are all -- from what I

23· · can see, they're all titled "Medication

24· · Management System Program Evaluation."

25· · · · · · · · · ·A. Yes.· However, I have two of

26· · one.

27· · · · · · · · · ·Q. Oh.

28· · · · · · · · · ·A. I have two that's dated

29· · September 2014 to September 22nd, '15.

30· · · · · · · · · ·Q. I might have mixed them up

31· · then.· Do you have one dated January to

32· · December 2014?

Page 7010·1· · · · · · · · · ·A. I do.

·2· · · · · · · · · ·Q. Do you have one dated August

·3· · 2015 to August 2016?

·4· · · · · · · · · ·A. I don't.

·5· · · · · · · · · ·THE COMMISSIONER:· I don't think

·6· · · · · · · · · ·I have the same ones either.· So

·7· · · · · · · · · ·Exhibit 19 has Woodstock and

·8· · · · · · · · · ·then date and September but no

·9· · · · · · · · · ·date; right?· That's Exhibit 19.

10· · · · · · · · · ·MR. KLOEZE:· That's correct.

11· · · · · · · · · ·THE COMMISSIONER:· All right.

12· · · · · · · · · ·What's the next one you think we

13· · · · · · · · · ·should have?

14· · · · · · · · · ·MR. KLOEZE:· It should have at

15· · · · · · · · · ·the top January to December

16· · · · · · · · · ·2014.

17· · · · · · · · · ·THE COMMISSIONER:· Okay.· That I

18· · · · · · · · · ·don't have, but I have two

19· · · · · · · · · ·December to November.· I think

20· · · · · · · · · ·that's the same one.· So I think

21· · · · · · · · · ·it may be that the witness

22· · · · · · · · · ·got --

23· · · · · · · · · ·THE WITNESS:· We just need to

24· · · · · · · · · ·swap?

25· · · · · · · · · ·THE COMMISSIONER:· I think so.

26· · · · · · · · · ·Maybe.· Okay.· Let's try that

27· · · · · · · · · ·again.· Just a sec.

28· · · · · · · · · ·MR. KLOEZE:· Let's go by doc ID

29· · · · · · · · · ·numbers at the bottom because we

30· · · · · · · · · ·have them all.

31· · · · · · · · · ·THE COMMISSIONER:· Okay.· All

32· · · · · · · · · ·right.· Doc ID numbers.

Page 7011·1· · · · · · · · · ·MR. KLOEZE:· The first is 43477.

·2· · · · · · · · · ·THE COMMISSIONER:· Okay. I

·3· · · · · · · · · ·don't have 43477.· I have 78,

·4· · · · · · · · · ·79, and 80.

·5· · · · · · · · · · · Okay.· I have two 77s then,

·6· · · · · · · · · ·so we don't need two 77s.· I'll

·7· · · · · · · · · ·give that one back.

·8· · · · · · · · · ·THE WITNESS:· Okay.· I think --

·9· · · · · · · · · ·I think I'm complete now.

10· · · · · · · · · ·MR. KLOEZE:· The second is

11· · · · · · · · · ·43480, and the third is 43478.

12· · · · · · · · · ·THE COMMISSIONER:· Right.· So

13· · · · · · · · · ·I think this might be yours.

14· · · · · · · · · ·That was the duplicate.

15· · · · · · · · · · · So this is what I have:· The

16· · · · · · · · · ·one that's currently marked as

17· · · · · · · · · ·43479, right, Exhibit 19.

18· · · · · · · · · ·MR. KLOEZE:· Yes.

19· · · · · · · · · ·THE COMMISSIONER:· I then have

20· · · · · · · · · ·in order 43477, 78, and 80.

21· · · · · · · · · ·MR. KLOEZE:· Yes.· I think date

22· · · · · · · · · ·order, the last two could

23· · · · · · · · · ·probably best be switched.· So

24· · · · · · · · · ·80 comes first and then 78

25· · · · · · · · · ·comes --

26· · · · · · · · · ·THE COMMISSIONER:· Okay.· All

27· · · · · · · · · ·right.· I see.· Okay.· Have you

28· · · · · · · · · ·got that too?

29· · · · · · · · · ·THE WITNESS:· I think I do.

30· · · · · · · · · ·THE COMMISSIONER:· All right.

31· · · · · · · · · ·Okay.· Do you want to -- should

32· · · · · · · · · ·we enter them as exhibits, and

Page 7012·1· · · · · · · · · ·then we can refer to the exhibit

·2· · · · · · · · · ·number, and then we'll all be --

·3· · · · · · · · · ·MR. KLOEZE:· That would be

·4· · · · · · · · · ·great.

·5· · · · · · · · · ·THE COMMISSIONER:· Okay.· So

·6· · · · · · · · · ·shall we do them in the order --

·7· · · · · · · · · ·date order or in the order of

·8· · · · · · · · · ·the documents?

·9· · · · · · · · · ·MR. KLOEZE:· I would prefer date

10· · · · · · · · · ·order.· I think it makes more

11· · · · · · · · · ·sense.

12· · · · · · · · · ·THE COMMISSIONER:· All right.

13· · · · · · · · · ·And so in your view, date order

14· · · · · · · · · ·is --

15· · · · · · · · · ·MR. KLOEZE:· 43477 would be the

16· · · · · · · · · ·next exhibit.

17· · · · · · · · · ·THE COMMISSIONER:· Okay.· And

18· · · · · · · · · ·then --

19· · · · · · · · · ·MR. KLOEZE:· 43480.

20· · · · · · · · · ·THE COMMISSIONER:· Yeah, and

21· · · · · · · · · ·then --

22· · · · · · · · · ·MR. KLOEZE:· 43478.

23· · · · · · · · · ·THE COMMISSIONER:· All right.

24· · · · · · · · · ·So just to be clear, then, for

25· · · · · · · · · ·everyone, document entitled

26· · · · · · · · · ·"Medication Management System

27· · · · · · · · · ·Program Evaluation" and the date

28· · · · · · · · · ·across the top says to December

29· · · · · · · · · ·2014, the date November 26/14;

30· · · · · · · · · ·correct?

31· · · · · · · · · ·MR. KLOEZE:· Yes.

32· · · · · · · · · ·THE COMMISSIONER:· And that,

Page 7013·1· · · · · · · · · ·Madam Clerk, if I'm correct, is

·2· · · · · · · · · ·Exhibit 138?

·3· · · · · · · · · ·THE REGISTRAR:· That's correct.

·4· · · · · · · · · ·THE COMMISSIONER:· Okay.

·5· · · · · · · · · ·Exhibit 138, and that's document

·6· · · · · · · · · ·ID 43477.

·7· · · · · · · · · ·EXHIBIT NO. 138:· Document

·8· · · · · · · · · ·entitled "Medication Management

·9· · · · · · · · · ·System Program Evaluation,"

10· · · · · · · · · ·Document 43477.

11· · · · · · · · · ·THE COMMISSIONER:· So document

12· · · · · · · · · ·ID 43480, same descriptor,

13· · · · · · · · · ·becomes Exhibit Number 139.

14· · · · · · · · · ·EXHIBIT NO. 139:· Document

15· · · · · · · · · ·entitled "Medication Management

16· · · · · · · · · ·System Program Evaluation,"

17· · · · · · · · · ·Document 43480.

18· · · · · · · · · ·THE COMMISSIONER:· And the same

19· · · · · · · · · ·descriptor, number 43478 is

20· · · · · · · · · ·Exhibit 140.

21· · · · · · · · · ·EXHIBIT NO. 140:· Document

22· · · · · · · · · ·entitled "Medication Management

23· · · · · · · · · ·System Program Evaluation,"

24· · · · · · · · · ·Document 43478.

25· · · · · · · · · ·THE REGISTRAR:· Counsel, you

26· · · · · · · · · ·handed up a 43479.

27· · · · · · · · · ·MR. KLOEZE:· That was my

28· · · · · · · · · ·mistake.· That was actually

29· · · · · · · · · ·Exhibit 19.

30· · · · · · · · · ·THE REGISTRAR:· Thank you.

31· · · · · · · · · ·THE COMMISSIONER:· All right.

32· · · · · · · · · ·BY MR. KLOEZE:

Page 7014·1· · · · · · · · · ·Q. And, Rhonda, these documents,

·2· · each of these program evaluations, you have a

·3· · stamp -- or there's a stamp at the upper left

·4· · hand of the page with your name on it?

·5· · · · · · · · · ·A. There is.

·6· · · · · · · · · ·Q. And what does that indicate?

·7· · · · · · · · · ·A. It indicates that I, an

·8· · inspector appointed under the act, certify this

·9· · to be a true copy of the original on the date

10· · when I took the copy, and I signed it.

11· · · · · · · · · ·Q. So this was evidence you

12· · collected during the course of your inspection?

13· · · · · · · · · ·A. Yes.

14· · · · · · · · · ·Q. Okay.· And one other document

15· · that I think we should enter before I ask you

16· · some questions on these:· Mr. Golden asked you

17· · whether or not you spoke to Sandra Fluttert at

18· · Caressant Care in the course of your

19· · inspection?

20· · · · · · · · · ·A. Yes.

21· · · · · · · · · ·Q. And whether or not you asked

22· · Ms. Fluttert some questions about the

23· · medication evaluation -- management evaluation?

24· · · · · · · · · ·A. Yes.

25· · · · · · · · · ·Q. Okay.· And you said that you

26· · would need to see the interview notes from your

27· · interview with Ms. Fluttert to be able to

28· · refresh your memory about that?

29· · · · · · · · · ·A. Yes.

30· · · · · · · · · ·Q. So we have the interview

31· · notes.· And can you identify Rhonda, are these

32· · the notes of the interview that you and Marian

Page 7015·1· · MacDonald had with Sandra Fluttert on

·2· · November 29, 2016?

·3· · · · · · · · · ·A. Yes.

·4· · · · · · · · · ·MR. KLOEZE:· Commissioner,

·5· · · · · · · · · ·before we lose the thread,

·6· · · · · · · · · ·perhaps we should enter this as

·7· · · · · · · · · ·the next exhibit.

·8· · · · · · · · · ·THE COMMISSIONER:· Exhibit 141

·9· · · · · · · · · ·then, the notes from the meeting

10· · · · · · · · · ·with Sandra Fluttert dated

11· · · · · · · · · ·November 29th, 2016.

12· · · · · · · · · ·EXHIBIT NO. 141:· Notes from the

13· · · · · · · · · ·meeting with Sandra Fluttert

14· · · · · · · · · ·dated November 29, 2016.

15· · · · · · · · · ·BY MR. KLOEZE:

16· · · · · · · · · ·Q. Now, going back to the four

17· · medication program evaluation documents,

18· · Rhonda, and one more document I want you to

19· · turn up, and that's the document that's at

20· · Tab J of your -- of the binder in front of you,

21· · the tabs that are attached to your Affidavit.

22· · · · · · · · · ·A. Yes.

23· · · · · · · · · ·Q. And that's the order -- or

24· · the inspection report from the EW inspection at

25· · CCW.· And I want you to turn to page 10, if you

26· · could.

27· · · · · · · · · ·And that's Document

28· · Number 43372, Laura, if you want to put it on

29· · the screen.

30· · · · · · · · · ·Now, you made a finding of

31· · noncompliance with respect to the home's

32· · failure to conduct an annual evaluation?

Page 7016·1· · · · · · · · · ·A. Yes.

·2· · · · · · · · · ·Q. And at the bottom of page 10,

·3· · you say that:· [AS READ]

·4· · · · · · · · · ·"The home provided documentation

·5· · · · · · · · · ·of four medication management

·6· · · · · · · · · ·system program evaluations

·7· · · · · · · · · ·completed."

·8· · Are these the four that we've just entered as

·9· · exhibits?

10· · · · · · · · · ·A. I believe so.

11· · · · · · · · · ·Q. And in your view, were these

12· · evaluation forms and the way they're filled

13· · out -- was that sufficient evidence for you to

14· · determine compliance of the home with respect

15· · to its obligation to conduct an annual

16· · evaluation --

17· · · · · · · · · ·A. No.

18· · · · · · · · · ·Q. -- of its medication system?

19· · · · · · · · · ·A. No.

20· · · · · · · · · ·Q. And why not?

21· · · · · · · · · ·A. Could I turn to the

22· · legislation that speaks to the --

23· · · · · · · · · ·Q. Absolutely.· You're turning

24· · to --

25· · · · · · · · · ·A. Although, I'm running out of

26· · room here.

27· · · · · · · · · ·Q. It's Section 116 of the reg.

28· · · · · · · · · ·A. Yes.· So 116 of the reg says:

29· · [AS READ]

30· · · · · · · · · ·"Every licensee of a long-term

31· · · · · · · · · ·care home shall ensure that a

32· · · · · · · · · ·team which must include the

Page 7017·1· · · · · · · · · ·interdisciplinary team which

·2· · · · · · · · · ·must include the Medical

·3· · · · · · · · · ·Director, the Administrator, the

·4· · · · · · · · · ·Director of Nursing and Personal

·5· · · · · · · · · ·Care, the Pharmacy Service

·6· · · · · · · · · ·Provider, and a Registered

·7· · · · · · · · · ·Dietitian who's a member of the

·8· · · · · · · · · ·staff of the home meets annually

·9· · · · · · · · · ·to evaluate the effectiveness of

10· · · · · · · · · ·the medication management system

11· · · · · · · · · ·in the home and to recommend any

12· · · · · · · · · ·changes to improve the system."

13· · So I would then be looking -- it also says

14· · under 116(5):· [AS READ]

15· · · · · · · · · ·"The licensee shall ensure that

16· · · · · · · · · ·a record is kept of the results

17· · · · · · · · · ·in the annual evaluation and of

18· · · · · · · · · ·any changes that were

19· · · · · · · · · ·implemented."

20· · It also specifies what needs to be included in

21· · that evaluation, including --· [AS READ]:

22· · · · · · · · · ·"The annual evaluation of the

23· · · · · · · · · ·medication management system

24· · · · · · · · · ·must include a review of the

25· · · · · · · · · ·quarterly evaluations in the

26· · · · · · · · · ·previous year as referred to in

27· · · · · · · · · ·Section 115, be undertaken using

28· · · · · · · · · ·an assessment instrument

29· · · · · · · · · ·designed specifically for this

30· · · · · · · · · ·purpose, and identify changes to

31· · · · · · · · · ·improve the system in accordance

32· · · · · · · · · ·with evidence-based practices,

Page 7018·1· · · · · · · · · ·and if there are none, in

·2· · · · · · · · · ·accordance with prevailing

·3· · · · · · · · · ·practices."

·4· · So I'd be looking for all those things to be

·5· · included in the record that was kept of that

·6· · evaluation.

·7· · · · · · · · · ·Q. And these forms are not

·8· · sufficient record of that?

·9· · · · · · · · · ·A. They are not.

10· · · · · · · · · ·Q. And can you just explain

11· · briefly why these forms are not sufficient

12· · record of that?

13· · · · · · · · · ·A. For one thing, the first one

14· · was -- the review was completed by Sandra

15· · Fluttert.· So that's one person.

16· · · · · · · · · ·Q. And it requires an

17· · interdisciplinary team to conduct this

18· · evaluation?

19· · · · · · · · · ·A. Yes.· And it didn't the

20· · include the administra -- all the people that I

21· · just said.

22· · · · · · · · · ·The second one was Sandra

23· · Fluttert and Agatha.· The third one was Agatha,

24· · Karen Routledge, Jennifer -- or Sandra

25· · Fluttert, and Jen Hague.· And the fourth one

26· · was Jen Emerson and Agatha K.

27· · · · · · · · · ·So the Director of Nursing and

28· · the Registered Dietitian and the Medical

29· · Director and all the other people that were

30· · identified there didn't participate in any of

31· · these.

32· · · · · · · · · ·Q. And so I don't want to go too

Page 7019·1· · much into this, but this -- I think you've

·2· · already confirmed, these forms in and of

·3· · themselves were not evidence of compliance?

·4· · · · · · · · · ·A. They were not.· They also

·5· · didn't include evaluation -- or the quarterly

·6· · evaluation, and it's unclear as to the time

·7· · period it was evaluating.

·8· · · · · · · · · ·It also -- I would look at an

·9· · evaluation as looking back at our system, what

10· · were our goals?· What did we do to achieve

11· · those goals?· How did we want to measure

12· · whether we were successful at that?· And did we

13· · accomplish that?· And do we need to do

14· · something different this year?· Do we need to

15· · set new goals?· Do we need to try different

16· · things?

17· · · · · · · · · ·And I didn't see evidence of

18· · that in this documentation from year to year.

19· · There was no relevance from year to year in any

20· · of the documentation.

21· · · · · · · · · ·There was -- I would also look

22· · at -- in their program -- in their evaluation

23· · at the end, they said areas for improvement.

24· · So I would look at that to say so that would be

25· · a goal they wanted to achieve the next year and

26· · see things that they did in order to achieve

27· · that goal that they had identified as an area

28· · of improvement the previous year, and that was

29· · not there.

30· · · · · · · · · ·It was also very -- so in the

31· · second one, the areas improvement were double

32· · checks.· I -- that's not -- that's not very

Page 7020·1· · clear.

·2· · · · · · · · · ·Q. Okay.· I do want to turn as

·3· · well to the interview with Sandra Fluttert.

·4· · You said that you did speak with Sandra

·5· · Fluttert about this.

·6· · · · · · · · · ·If you can turn to the document

·7· · that's now Exhibit 141 and turn to page 3 of

·8· · that document at the bottom of that, and that's

·9· · Doc Number 71590.

10· · · · · · · · · ·A. Yes.

11· · · · · · · · · ·Q. We'll wait for it to come up

12· · on the screen.

13· · · · · · · · · ·A. Okay.· Sorry.· Thought I

14· · missed something.

15· · · · · · · · · ·Q. I'm going to make you read a

16· · bit once we get there.

17· · · · · · · · · ·A. Okay.· I can do that.

18· · · · · · · · · ·Q. It's the bottom of page 3 of

19· · that document and the question starting

20· · Number 11.· There it is.

21· · · · · · · · · ·And the question you asked

22· · Sandra Fluttert was:· [AS READ]

23· · · · · · · · · ·"Did you ever participate in a

24· · · · · · · · · ·medication management system

25· · · · · · · · · ·evaluation."

26· · And what was her answer to that?

27· · · · · · · · · ·A. [AS READ]:

28· · · · · · · · · ·"I did medication audits.· So I

29· · · · · · · · · ·would go through the chart and

30· · · · · · · · · ·make sure that what was ordered

31· · · · · · · · · ·was in the computer and make

32· · · · · · · · · ·sure things were signed off

Page 7021·1· · · · · · · · · ·which a lot of times they

·2· · · · · · · · · ·weren't.· And I would flag them

·3· · · · · · · · · ·and put them in the doctor's

·4· · · · · · · · · ·book, and then a lot of times I

·5· · · · · · · · · ·would find orders that weren't

·6· · · · · · · · · ·processed or orders that had

·7· · · · · · · · · ·been done wrong and had been

·8· · · · · · · · · ·checked by a couple of nurses,

·9· · · · · · · · · ·so then I'd have to go.

10· · · · · · · · · · · Was there ever a formal

11· · · · · · · · · ·evaluation process of the

12· · · · · · · · · ·medication management system?"

13· · · · · · · · · ·Q. That was a question you

14· · asked?

15· · · · · · · · · ·A. That was a question we asked.

16· · · · · · · · · ·Q. And her answer was?

17· · · · · · · · · ·A. [AS READ]:

18· · · · · · · · · ·"Oh, yes, the year, yes, but

19· · · · · · · · · ·they always said everything was

20· · · · · · · · · ·good."

21· · · · · · · · · ·Q. And then you asked a further

22· · question?

23· · · · · · · · · ·A. [AS READ]:

24· · · · · · · · · ·"So who would participate in

25· · · · · · · · · ·that evaluation?"

26· · · · · · · · · ·Q. And the answer was?

27· · · · · · · · · ·A. [AS READ]:

28· · · · · · · · · ·"We did it at a management

29· · · · · · · · · ·meeting.· And if you brought up

30· · · · · · · · · ·that they didn't do -- they

31· · · · · · · · · ·didn't --"

32· · Sorry.

Page 7022·1· · · · · · · · · ·"And if you brought up that they

·2· · · · · · · · · ·don't do that really well, no

·3· · · · · · · · · ·really do that well."

·4· · I can't read right now, so maybe not.

·5· · · · · · · · · ·"Oh, yes, they do.· They put

·6· · · · · · · · · ·works out good.· You had 'yes'

·7· · · · · · · · · ·or 'no' on the thing, whether it

·8· · · · · · · · · ·was working and when it always

·9· · · · · · · · · ·was yes even if you disagreed."

10· · · · · · · · · ·Q. And then your next question

11· · was?

12· · · · · · · · · ·A. [AS READ]:

13· · · · · · · · · ·"Who else would have been

14· · · · · · · · · ·involved besides management?

15· · · · · · · · · ·Would pharmacy have been

16· · · · · · · · · ·involved or the physician?"

17· · And she said no.

18· · · · · · · · · ·Q. And based on this interview

19· · with Sandra Fluttert, was that evidence of

20· · compliance with the obligation to have an

21· · annual medication evaluation of their --

22· · evaluation of their medication management

23· · system?

24· · · · · · · · · ·A. So, yes, that was another

25· · piece of evidence to support noncompliance.

26· · Sorry, I didn't answer that very well.

27· · · · · · · · · ·Q. And I understand in part it

28· · was noncompliance because not all the people

29· · who needed to be involved in that were

30· · involved?

31· · · · · · · · · ·A. At a very basic level, that

32· · would have been enough.· With the documentation

Page 7023·1· · of that and the interviews of that, that would

·2· · have been noncompliance with that section.

·3· · · · · · · · · ·Q. Okay.· One other question

·4· · that Mr. Golden asked you, it was about the

·5· · mandatory management order.· And if you can

·6· · turn to Tab M again in the binder in front of

·7· · you.· It's your Affidavit.· And we're looking

·8· · at the mandatory management order.· And at

·9· · page 7 was the page that Mr. Golden took you

10· · to.

11· · · · · · · · · ·And Ms. Fraser already took you

12· · to this as well, so I'm not going to spend too

13· · much time on it.· Oh, sorry, Laura.· It's Doc

14· · Number 39100, page 7, the section starting

15· · "medication administration."· Those two bullet

16· · points are enough.

17· · · · · · · · · ·So as I understand it, this is

18· · sort of a chronology of the inspection activity

19· · at CCW.· This bullet, the first bullet under

20· · "medication administration" is with respect to

21· · findings of noncompliance and compliance orders

22· · in respect of Section 131?

23· · · · · · · · · ·A. Yes.

24· · · · · · · · · ·Q. And that's the section

25· · dealing with medication errors?

26· · · · · · · · · ·A. Medication administration.

27· · · · · · · · · ·Q. Medication administration?

28· · · · · · · · · ·A. Yes.

29· · · · · · · · · ·Q. So it's a section that

30· · requires the licensee to administer all

31· · medications in accordance with the directions

32· · of use?

Page 7024·1· · · · · · · · · ·A. Yes.

·2· · · · · · · · · ·Q. And as I understand it here,

·3· · we see on January 25th, 2017, there was a

·4· · compliance order?

·5· · · · · · · · · ·A. Yes.

·6· · · · · · · · · ·Q. With a compliance date of

·7· · January 27th?

·8· · · · · · · · · ·A. Yes.

·9· · · · · · · · · ·Q. And then inspectors went in

10· · again, and that order was not complied with and

11· · was reissued on June 29th?

12· · · · · · · · · ·A. Yes.

13· · · · · · · · · ·Q. And that had a compliance

14· · date of July 28th?

15· · · · · · · · · ·A. Yes.

16· · · · · · · · · ·Q. And that order -- so that's

17· · the second time has not been complied with.

18· · Inspectors went in again and made a third order

19· · on August 24th?

20· · · · · · · · · ·A. Yes.

21· · · · · · · · · ·Q. So that's three consecutive

22· · orders on the same section?

23· · · · · · · · · ·A. Yes.

24· · · · · · · · · ·Q. And then what is your action

25· · after you find those three orders?· What's the

26· · next thing you do that's set out here?

27· · · · · · · · · ·A. I have to issue a director

28· · referral.

29· · · · · · · · · ·Q. And what does that mean?

30· · Sorry, go ahead.

31· · · · · · · · · ·A. It's one of the items that's

32· · identified in the judgment matrix.· It would go

Page 7025·1· · with a written notification and usually also

·2· · goes with a compliance order, but it's

·3· · notifying the director that this has been

·4· · reissued for the third time, and/or there's a

·5· · serious enough matter that the director needs

·6· · to be notified of something.

·7· · · · · · · · · ·Q. In this case, it was -- it

·8· · was reissued for the third time?

·9· · · · · · · · · ·A. It was.

10· · · · · · · · · ·Q. And we don't have to go back

11· · under the second one, but I can see as

12· · Ms. Fraser brought you through, under Section

13· · 135, again, there were at least two consecutive

14· · orders --

15· · · · · · · · · ·A. Yes.

16· · · · · · · · · ·Q. -- that were not complied

17· · with?

18· · · · · · · · · ·A. Yes.

19· · · · · · · · · ·Q. And after that, that, again,

20· · was referred to the director.· You made a

21· · referral to the director?

22· · · · · · · · · ·A. Yes.· So during that

23· · inspection, we had regular weekly contact with

24· · the director, and she was aware of what was

25· · happening and what our findings were.

26· · · · · · · · · ·And given that both of those

27· · sections were issued as immediate orders in

28· · January and that 131 had been issued for the

29· · third time and a director referral was made and

30· · it was the second time for 135 because we had

31· · deferred the follow-up in May, that because

32· · those two findings essentially go together, the

Page 7026·1· · concerns -- they correlate.

·2· · · · · · · · · ·The director said make that one

·3· · a director's referral as well so that she could

·4· · have the information related to that as well.

·5· · · · · · · · · ·Q. And once it's referred to the

·6· · director, then it's up to the director to make

·7· · a decision as to what she's going to do with

·8· · this information?

·9· · · · · · · · · ·A. Yes.· I don't direct the

10· · director.· She directs me.

11· · · · · · · · · ·Q. Okay.· And the thing that the

12· · director did with this information is actually

13· · this mandatory management order?

14· · · · · · · · · ·A. Yes.

15· · · · · · · · · ·Q. Thank you.· Mr. Golden also

16· · asked you finally about interviews you

17· · undertook at Caressant Care Woodstock,

18· · interviews you had with the staff there?

19· · · · · · · · · ·A. Yes.

20· · · · · · · · · ·Q. I just want to turn you to

21· · paragraph 100 of your Affidavit, page 38.· And

22· · this is the paragraph that describes sort of

23· · the -- you were told that you could proceed to

24· · interview -- start your interviews at

25· · Caressant Care, and your first interview was

26· · with the Director of Care?

27· · · · · · · · · ·A. Yes.

28· · · · · · · · · ·Q. And that's Helen Crombez?

29· · · · · · · · · ·A. Yes.

30· · · · · · · · · ·Q. And --

31· · · · · · · · · ·MR. GOLDEN:· I rise because this

32· · · · · · · · · ·paragraph was expressly covered

Page 7027·1· · · · · · · · · ·in chief.· This is not a new

·2· · · · · · · · · ·issue that I raised, and

·3· · · · · · · · · ·certainly when I was questioning

·4· · · · · · · · · ·about the interviews, I wasn't

·5· · · · · · · · · ·challenging this.

·6· · · · · · · · · · · This is all covered in chief.

·7· · · · · · · · · ·I don't see how I raised an

·8· · · · · · · · · ·issue that was new that is now

·9· · · · · · · · · ·causing proper reply to come

10· · · · · · · · · ·back to a paragraph that was

11· · · · · · · · · ·already addressed in chief.

12· · · · · · · · · ·THE COMMISSIONER:· Let me hear

13· · · · · · · · · ·the question, and then we'll see

14· · · · · · · · · ·where it arose from.

15· · · · · · · · · ·BY MR. KLOEZE:

16· · · · · · · · · ·Q. Mr. Golden asked you the

17· · question whether or not you felt that the

18· · staff, who understandably were going through a

19· · traumatic experience, whether you thought they

20· · were prepared enough to respond to an

21· · interview.

22· · · · · · · · · ·And I see from this paragraph

23· · that you conducted that interview over not just

24· · one instance but a number of instances.· Can

25· · you describe that and sort of the conduct of

26· · your interview with Ms. Crombez?

27· · · · · · · · · ·THE COMMISSIONER:· Just help me

28· · · · · · · · · ·understand how this arises from

29· · · · · · · · · ·the cross-examination.· It was

30· · · · · · · · · ·covered in chief.

31· · · · · · · · · ·MR. KLOEZE:· Mr. Golden's

32· · · · · · · · · ·question to this witness was

Page 7028·1· · · · · · · · · ·whether or not she felt that the

·2· · · · · · · · · ·people -- the people she

·3· · · · · · · · · ·interviewed at Caressant Care

·4· · · · · · · · · ·Woodstock were prepared enough

·5· · · · · · · · · ·given the shock of the situation

·6· · · · · · · · · ·and the fact that they're

·7· · · · · · · · · ·showing up to interview them

·8· · · · · · · · · ·without the ability to prepare.

·9· · · · · · · · · · · I just wanted to ask her what

10· · · · · · · · · ·her view is on that and whether

11· · · · · · · · · ·or not she felt she gave them

12· · · · · · · · · ·opportunities to reflect and

13· · · · · · · · · ·prepare for the interview.

14· · · · · · · · · ·MR. GOLDEN:· I think she was

15· · · · · · · · · ·already very clear they had no

16· · · · · · · · · ·opportunity to prepare.· They

17· · · · · · · · · ·weren't told ahead of time what

18· · · · · · · · · ·the subject matter was.· They

19· · · · · · · · · ·weren't given an opportunity to

20· · · · · · · · · ·look at records.

21· · · · · · · · · · · But my specific question was

22· · · · · · · · · ·was she given an explanation

23· · · · · · · · · ·regarding the impact of this

24· · · · · · · · · ·kind of trauma on persons'

25· · · · · · · · · ·ability to remember and their

26· · · · · · · · · ·judgment.· That was what my

27· · · · · · · · · ·question was, and she said no.

28· · · · · · · · · ·THE COMMISSIONER:· That's my

29· · · · · · · · · ·recollection.· What Mr. Golden

30· · · · · · · · · ·said was that his question was

31· · · · · · · · · ·directed at whether or not she

32· · · · · · · · · ·had training to be able to

Page 7029·1· · · · · · · · · ·effectively assess their

·2· · · · · · · · · ·responses in the stress of the

·3· · · · · · · · · ·situation.

·4· · · · · · · · · ·MR. KLOEZE:· I understand the --

·5· · · · · · · · · ·in the preamble to his question

·6· · · · · · · · · ·and he made comments about this

·7· · · · · · · · · ·witness's -- this witness had

·8· · · · · · · · · ·the opportunity to reflect and

·9· · · · · · · · · ·prepare and gather documents,

10· · · · · · · · · ·and that's --

11· · · · · · · · · ·THE COMMISSIONER:· The inspector

12· · · · · · · · · ·did.· This witness we're talking

13· · · · · · · · · ·about.

14· · · · · · · · · ·MR. KLOEZE:· This witness

15· · · · · · · · · ·sitting here today giving

16· · · · · · · · · ·evidence.

17· · · · · · · · · ·THE COMMISSIONER:· Right.

18· · · · · · · · · ·MR. KLOEZE:· And whether or not

19· · · · · · · · · ·the staff at Caressant Care had

20· · · · · · · · · ·that same opportunity.

21· · · · · · · · · ·THE COMMISSIONER:· I don't think

22· · · · · · · · · ·that was part of the question.

23· · · · · · · · · ·If you want to pursue this, then

24· · · · · · · · · ·I think we have to hear the --

25· · · · · · · · · ·read back -- have a read-back on

26· · · · · · · · · ·it.

27· · · · · · · · · ·MR. KLOEZE:· I'm willing to

28· · · · · · · · · ·continue and proceed.

29· · · · · · · · · ·THE COMMISSIONER:· All right.

30· · · · · · · · · ·Thank you.

31· · · · · · · · · ·BY MR. KLOEZE:

32· · · · · · · · · ·Q. I just have one more

Page 7030·1· · question, Rhonda.· Ms. Fraser asked you a

·2· · question about the home's -- long-term care

·3· · homes operating in an environment of zero

·4· · accountability, and I wanted to ask you whether

·5· · or not you believe --

·6· · · · · · · · · ·MS. FRASER:· I believe I said

·7· · · · · · · · · ·zero tolerance.

·8· · · · · · · · · ·MR. KLOEZE:· Zero --

·9· · · · · · · · · ·THE COMMISSIONER:· Tolerance.

10· · · · · · · · · ·MS. FRASER:· Tolerance for abuse

11· · · · · · · · · ·and neglect.· Maybe I should let

12· · · · · · · · · ·him say the whole question, but

13· · · · · · · · · ·in the words of zero, I'm pretty

14· · · · · · · · · ·sure I meant to say zero

15· · · · · · · · · ·tolerance for abuse and neglect.

16· · · · · · · · · ·MR. KLOEZE:· That might be a

17· · · · · · · · · ·better clarification of the

18· · · · · · · · · ·question.· I had thought the

19· · · · · · · · · ·question was whether or not

20· · · · · · · · · ·there is an environment of zero

21· · · · · · · · · ·accountability.

22· · · · · · · · · ·THE COMMISSIONER:· I think it

23· · · · · · · · · ·was zero tolerance.

24· · · · · · · · · ·MR. KLOEZE:· Okay.· Then I'm

25· · · · · · · · · ·happy to withdraw that question

26· · · · · · · · · ·as well.

27· · · · · · · · · ·THE COMMISSIONER:· That's good.

28· · · · · · · · · ·We're making progress.

29· · · · · · · · · ·MR. KLOEZE:· And with that,

30· · · · · · · · · ·Rhonda, I'm finished my

31· · · · · · · · · ·questions.

32· · · · · · · · · ·THE COMMISSIONER:· Thank you.

Page 7031·1· · · · · · · · · ·Did the Commission Counsel have

·2· · · · · · · · · ·any re-exam?

·3· · · · · · · · · ·MS. STEPHENS:· I have no

·4· · · · · · · · · ·questions in reply, but we have

·5· · · · · · · · · ·notice that Exhibit 141 --

·6· · · · · · · · · ·I believe it was the last

·7· · · · · · · · · ·exhibit with the interview

·8· · · · · · · · · ·notes, that that should be

·9· · · · · · · · · ·marked as an exhibit subject to

10· · · · · · · · · ·redactions.· Some redactions are

11· · · · · · · · · ·necessarily there that had not

12· · · · · · · · · ·previously happened.

13· · · · · · · · · ·THE COMMISSIONER:· All right.

14· · · · · · · · · ·Thank you.· So Exhibit 141 is

15· · · · · · · · · ·entered subject to redaction in

16· · · · · · · · · ·that, as we all know, has

17· · · · · · · · · ·implications for when it will be

18· · · · · · · · · ·posted on the website.· Thank

19· · · · · · · · · ·you.

20· · · · · · · · · ·MS. STEPHENS:· Thank you.

21· · · · · · · · · ·THE COMMISSIONER:· All right.

22· · · · · · · · · ·So that is my pleasant task to

23· · · · · · · · · ·thank you for coming.· We know

24· · · · · · · · · ·that it is not easy, and it's

25· · · · · · · · · ·particularly not easy when we

26· · · · · · · · · ·have to show our feelings in

27· · · · · · · · · ·public, so we appreciate all of

28· · · · · · · · · ·your help, and thank you.

29· · · · · · · · · ·THE WITNESS:· And I'm free to

30· · · · · · · · · ·go; right?

31· · · · · · · · · ·THE COMMISSIONER:· You're free

32· · · · · · · · · ·to go.· I'm sorry.· I should

Page 7032·1· · · · · · · · · ·have said the magic words, the

·2· · · · · · · · · ·ones you were waiting for.

·3· · · · · · · · · ·You're free to go.

·4· · · · · · · · · ·THE WITNESS:· I really wanted to

·5· · · · · · · · · ·hear those words.

·6· · · · · · · · · ·THE COMMISSIONER:· Well, good.

·7· · · · · · · · · ·I said them then.

·8· · · · · · · · · ·MR. GOLDEN:· Commissioner, in

·9· · · · · · · · · ·terms of what we're going to do

10· · · · · · · · · ·next, I'm sure you recall

11· · · · · · · · · ·Carol Hepting gave considerable

12· · · · · · · · · ·evidence.· There's hundreds of

13· · · · · · · · · ·pages of her transcript.

14· · · · · · · · · · · There was an agreement

15· · · · · · · · · ·reached towards the end of the

16· · · · · · · · · ·cross-examination of her that

17· · · · · · · · · ·she would be brought back to

18· · · · · · · · · ·answer questions on three

19· · · · · · · · · ·documents to answer the

20· · · · · · · · · ·questions of the Ministry lawyer

21· · · · · · · · · ·and the OARC lawyer.· And those

22· · · · · · · · · ·documents are Exhibit 87,

23· · · · · · · · · ·Exhibit 88, and Exhibit 56.

24· · · · · · · · · · · We have those documents here

25· · · · · · · · · ·in the materials that were

26· · · · · · · · · ·used -- or two of the three for

27· · · · · · · · · ·those witnesses.

28· · · · · · · · · · · Exhibit 56 is the lengthy

29· · · · · · · · · ·inspection report, 43372.

30· · · · · · · · · ·That's the January 24 to

31· · · · · · · · · ·August 15 report.

32· · · · · · · · · · · Then we have the director's

Page 7033·1· · · · · · · · · ·order regarding mandatory

·2· · · · · · · · · ·management.· That's 39100.

·3· · · · · · · · · · · And then there's the

·4· · · · · · · · · ·hand-delivered letter to

·5· · · · · · · · · ·Caressant Care January 25, 2017.

·6· · · · · · · · · ·That's 39106.· It's Exhibit 88.

·7· · · · · · · · · · · And Ms. Hepting has -- I was

·8· · · · · · · · · ·going to say happily returned.

·9· · · · · · · · · ·She has returned to answer

10· · · · · · · · · ·questions on those three

11· · · · · · · · · ·documents, and then I might have

12· · · · · · · · · ·some re-exam depending on what's

13· · · · · · · · · ·asked.

14· · · · · · · · · ·THE COMMISSIONER:· Thank you.

15· · · · · · · · · ·Can I just clarify because I

16· · · · · · · · · ·will ask that the clerk provide

17· · · · · · · · · ·me with those three exhibits.

18· · · · · · · · · · · Does Ms. Hepting have a copy

19· · · · · · · · · ·of those exhibits available at

20· · · · · · · · · ·the table for her, at the

21· · · · · · · · · ·witness table?

22· · · · · · · · · · · If not, if we take a short

23· · · · · · · · · ·recess, my marked-up documents I

24· · · · · · · · · ·can use, and then we can give

25· · · · · · · · · ·the witness the clean copy for

26· · · · · · · · · ·the record.

27· · · · · · · · · · · And so I'm happy to do that,

28· · · · · · · · · ·but I think we just want to make

29· · · · · · · · · ·sure we've got the documents in

30· · · · · · · · · ·front of everybody who wants to.

31· · · · · · · · · ·MS. FRASER:· They're in a couple

32· · · · · · · · · ·different places, Commissioner,

Page 7034·1· · · · · · · · · ·so I'm sure we can get her a

·2· · · · · · · · · ·clean copy.· We have a few

·3· · · · · · · · · ·minutes to get it organized.

·4· · · · · · · · · ·THE COMMISSIONER:· Okay.· So

·5· · · · · · · · · ·then we'll recess for five

·6· · · · · · · · · ·minutes.· I'll get my copies,

·7· · · · · · · · · ·and the clerk can give those

·8· · · · · · · · · ·copies to the -- put them on

·9· · · · · · · · · ·witness table for her.

10· · · · · · · · · ·THE REGISTRAR:· This Public

11· · · · · · · · · ·Inquiry is adjourned for five

12· · · · · · · · · ·minutes.

13· · · · · · · · · ·-- RECESSED AT 3:18 P.M. --

14· · · · · · · · · ·-- RESUMED AT 3:30 P.M. --

15· · · · · · · · · ·THE COMMISSIONER:· Thank you

16· · · · · · · · · ·very much.· Just before we

17· · · · · · · · · ·begin, Ms. Hepting, I just want

18· · · · · · · · · ·to remind you, you know that

19· · · · · · · · · ·you're still under oath?

20· · · · · · · · · ·THE WITNESS:· Okay.

21· · · · · · · · · ·THE COMMISSIONER:· Thank you.

22· · · · · · · · · ·CAROL HEPTING:· UNDER PRIOR

23· · · · · · · · · ·OATH.

24· · · · · · · · · ·MS. FRASER:· Thank you,

25· · · · · · · · · ·Commissioner.· And just I'm

26· · · · · · · · · ·always grateful for the very

27· · · · · · · · · ·conscientious court staff and

28· · · · · · · · · ·support that we have here

29· · · · · · · · · ·supporting us and making us look

30· · · · · · · · · ·our best.· So thank them for

31· · · · · · · · · ·helping us with this issue.

32· · · · · · · · · ·FURTHER CROSS-EXAMINATION BY MS.

Page 7035·1· · · · · · · · · ·FRASER:

·2· · · · · · · · · ·Q. Ms. Hepting, you'll recall

·3· · I'm Suzan Fraser?

·4· · · · · · · · · ·A. Yes.

·5· · · · · · · · · ·Q. Okay.· When we broke last

·6· · time -- and I'm grateful for you coming back.

·7· · I can appreciate how difficult it is when

·8· · you're expecting to be done, and then you're

·9· · asked to come back a month later.

10· · · · · · · · · ·In your absence, we've heard

11· · quite a bit about orders of the Ministry of

12· · Health which ultimately resulted in a mandatory

13· · management order.

14· · · · · · · · · ·And you're familiar with a

15· · number of different orders that ultimately

16· · resulted in an order of the director of the

17· · Ministry of Health being made on September the

18· · 1st, 2017?

19· · · · · · · · · ·A. Yes.

20· · · · · · · · · ·Q. Okay.· And you'll find a copy

21· · of the order of the director, which is

22· · Exhibit 87 to these proceedings, in one of

23· · those three documents that is before you.· And

24· · it should have 87 written on the top.· And for

25· · everyone else following along, it's doc ID

26· · 39100.

27· · · · · · · · · ·And, Ms. Hepting, you read this

28· · document when the director issued it?

29· · · · · · · · · ·A. Yes.

30· · · · · · · · · ·Q. You became aware of it?

31· · · · · · · · · ·A. Yes.

32· · · · · · · · · ·Q. Okay.· And we understand that

Page 7036·1· · this order was not appealed?

·2· · · · · · · · · ·A. That's correct.

·3· · · · · · · · · ·Q. All right.· And have you

·4· · reread this document in preparation for coming

·5· · here today?

·6· · · · · · · · · ·A. Yes.

·7· · · · · · · · · ·Q. Okay.· And as director --

·8· · vice president of operations, this is an order

·9· · that you would have been intimately familiar

10· · with at the time it was issued and any efforts

11· · to ensure compliance following it; is that

12· · fair?

13· · · · · · · · · ·A. Yes and no.· This was issued

14· · September 1st.

15· · · · · · · · · ·Q. Yes.

16· · · · · · · · · ·A. In that time, we had made

17· · some changes.· The VP of quality was over at

18· · the home full-time then.· She was dealing more

19· · with the day-to-day stuff or business than I

20· · was.

21· · · · · · · · · ·Q. At what point in time did the

22· · VP of quality assurance enter the home?· I'll

23· · take you through the order because I think it

24· · actually references that.

25· · · · · · · · · ·If you turn to page 10 of the

26· · order, partway down the page -- oh, I'm sorry.

27· · I've lost my place.· Maybe you can -- do you

28· · know at what point in time the VP of quality

29· · assurance came into the home?

30· · · · · · · · · ·A. It would be just before that

31· · date of August 14th.

32· · · · · · · · · ·Q. Okay.

Page 7037·1· · · · · · · · · ·A. It was after the long weekend

·2· · in August.

·3· · · · · · · · · ·Q. Okay.· So midway down that

·4· · page 10 -- you actually had it on the screen,

·5· · Laura.· Thanks.· If you can -- it says:· [AS

·6· · READ]

·7· · · · · · · · · ·"On August 14th, 2017, the

·8· · · · · · · · · ·licensee president of

·9· · · · · · · · · ·Caressant Care nursing and

10· · · · · · · · · ·retirement homes Ltd. --"

11· · And just to stop there, that's Mr. Jim Lavelle?

12· · · · · · · · · ·A. Yes.

13· · · · · · · · · ·Q. Okay.· [AS READ]:

14· · · · · · · · · ·"-- provided the Ministry with a

15· · · · · · · · · ·letter indicating that as of

16· · · · · · · · · ·that date, the vice president of

17· · · · · · · · · ·quality improvement would be the

18· · · · · · · · · ·head office person responsible

19· · · · · · · · · ·for the home."

20· · So as of that date, it was the VP of quality

21· · improvement who would be taking responsibility

22· · for the home?

23· · · · · · · · · ·A. Yes.

24· · · · · · · · · ·Q. But up until that point in

25· · time, dealing with the Ministry inspections and

26· · trying to ensure compliance had been your

27· · responsibility, working with other staff?

28· · · · · · · · · ·A. Working with other staff,

29· · yes.

30· · · · · · · · · ·Q. But you were the most senior

31· · person responsible for that job; right?

32· · · · · · · · · ·A. Yes.

Page 7038·1· · · · · · · · · ·Q. Okay.· And did Mr. Lavelle

·2· · provide you with any assistance whatsoever in

·3· · either dealing with the inspections or trying

·4· · to ensure compliance between October the 5th,

·5· · 2016, and August the 14th, 2017?

·6· · · · · · · · · ·A. What kind of assistance?

·7· · · · · · · · · ·Q. I don't know.· Did he help

·8· · you at all?

·9· · · · · · · · · ·A. Oh, he was -- he was quite

10· · aware.· He was quite involved.· And we did hire

11· · an external consultant.

12· · · · · · · · · ·Q. Okay.· So looking at the

13· · report, you will agree with me that the

14· · director makes a number of findings of failure

15· · to comply with the legislation.· Do you agree

16· · with that?· You nodded your head.· You have to

17· · give --

18· · · · · · · · · ·A. Yes.· You're referring to

19· · this in general, this document?

20· · · · · · · · · ·Q. Yes.· For -- well, first of

21· · all, let's go to the page 5 of the document.

22· · And that's the part of the document where

23· · there's a citing of management instability?

24· · · · · · · · · ·A. Yes.

25· · · · · · · · · ·Q. Okay.· And you agree that

26· · during the period of time between September the

27· · 30th, 2016, and March of -- actually, July of

28· · 2017, there was significant management

29· · instability?

30· · · · · · · · · ·A. I would agree there had been

31· · management turnover.

32· · · · · · · · · ·Q. Okay.· It references here

Page 7039·1· · that the Director of Nursing with approximately

·2· · 30 years of service was terminated; is that

·3· · correct in your view?

·4· · · · · · · · · ·A. That was the composer of this

·5· · document, who I believe was the director of the

·6· · Ministry of Health.· That was her

·7· · interpretation of what she had heard.· The

·8· · Director of Nursing actually retired.

·9· · · · · · · · · ·Q. So, in your view, Ms. Crombez

10· · retired or resigned?

11· · · · · · · · · ·A. Retired, resigned, yes.

12· · · · · · · · · ·Q. Which one of those two

13· · things?

14· · · · · · · · · ·A. Retired.

15· · · · · · · · · ·Q. Okay.

16· · · · · · · · · ·A. At least we had a retirement

17· · home party for her.

18· · · · · · · · · ·Q. So you had a party for

19· · Ms. Crombez.· Okay.

20· · · · · · · · · ·Now, turning to page 6 of that

21· · document, the director cites a number of

22· · failures related to resident care and safety

23· · falling under of title of "Multiple and

24· · Repeated Noncompliance in 2016 to 2017."· Am I

25· · correct about that?

26· · · · · · · · · ·A. I see that, yes.

27· · · · · · · · · ·Q. Okay.· And she indicates on

28· · page 7 of her report that there was

29· · noncompliance with respect to protecting

30· · residents from abuse and neglect.· She goes on

31· · to make findings regarding medication and

32· · administration.

Page 7040·1· · · · · · · · · ·And then on page 8 of the

·2· · document -- and I'm not going through

·3· · everything -- the director finds the licensee

·4· · has demonstrated a continued inability to fully

·5· · understand the scope and severity of

·6· · noncompliance and the issues involved as well

·7· · as what actions are required and what resources

·8· · and effort are needed to be in place at the

·9· · home to comply with the compliance orders,

10· · implement plans, and achieve and sustain

11· · compliance with the requirements of the

12· · Long-Term Care Homes Act; right?· That's

13· · something that she comments on?

14· · · · · · · · · ·A. Yes.

15· · · · · · · · · ·Q. Okay.· And turning the page

16· · to page 9, she cites instances -- look at

17· · March 19th -- of you requesting that the

18· · Ministry inspectors reinspect as the home was

19· · ready for a follow-up inspection.· You agree?

20· · · · · · · · · ·A. That was the process we were

21· · to follow.

22· · · · · · · · · ·Q. And by March 19th, you were

23· · of the view that you were ready for that

24· · follow-up inspection, and, however, when the

25· · Ministry returned, you were unable to achieve

26· · compliance.· Do you agree?

27· · · · · · · · · ·A. We had some areas that

28· · were -- still needed further addressing.

29· · · · · · · · · ·Q. Right.· But what she found --

30· · what she goes on to find -- I'll just take you

31· · to the bottom of -- at August the 2nd,

32· · follow-up inspection:· [AS READ]

Page 7041·1· · · · · · · · · ·"The vice president of

·2· · · · · · · · · ·operations came into the home to

·3· · · · · · · · · ·talk to the inspectors and to

·4· · · · · · · · · ·inquire about the progress of

·5· · · · · · · · · ·the inspection and was very

·6· · · · · · · · · ·surprised when informed that

·7· · · · · · · · · ·there was not enough evidence to

·8· · · · · · · · · ·support compliance."

·9· · Right?· You thought you were compliant, and you

10· · were surprised when they found that there was

11· · not enough evidence to support compliance.· And

12· · I guess what my --

13· · · · · · · · · ·A. I didn't go to the home to

14· · meet with them and check with the progress. I

15· · was at the home for a different reason.

16· · · · · · · · · ·Q. Okay.

17· · · · · · · · · ·A. I did go in and speak with

18· · them and -- because I wanted to introduce

19· · myself to the one inspector I'd never met.

20· · · · · · · · · ·Q. Right.· But it's my

21· · understanding, based on this report, that

22· · despite clear orders outlining the steps that

23· · were required to be taken to correct the

24· · noncompliance, that you were not aware of those

25· · requirements or your progress in meeting them?

26· · · · · · · · · ·A. Actually, no, I don't agree

27· · with that.· We had --

28· · · · · · · · · ·Q. So just if I can stop you

29· · there.· Were you not the licensee's

30· · representative up until that point in time?

31· · · · · · · · · ·A. Yes.

32· · · · · · · · · ·Q. Okay.

Page 7042·1· · · · · · · · · ·A. It's referring to me.

·2· · · · · · · · · ·Q. Okay.· But you disagree with

·3· · that finding?

·4· · · · · · · · · ·A. I disagree with that

·5· · statement, that we weren't aware we had done --

·6· · we had done so much work in that period of

·7· · time.· What Ms. Kukoly showed me that day was,

·8· · yes, a surprise to me.· I'd have to agree with

·9· · that.

10· · · · · · · · · ·But we had developed a tracking

11· · tool.· There was two staff that weren't on that

12· · tracking tool.· They had developed an action

13· · plan.· It wasn't entitled a "quality

14· · improvement plan," but they had developed an

15· · action plan.· There was -- we had taken action.

16· · This makes it sound like we hadn't done

17· · anything.

18· · · · · · · · · ·Q. Right, but what I'm more

19· · concerned about and I guess the real question I

20· · have for you, Ms. Hepting, is how can it be

21· · that you, as somebody who is the VP of

22· · operations for over 15 homes, did not have an

23· · appreciation of what it would take to bring the

24· · home into compliance?

25· · · · · · · · · ·A. And I don't agree with that

26· · statement.

27· · · · · · · · · ·Q. Okay.· So you disagree with

28· · the findings of --

29· · · · · · · · · ·A. I disagree with --

30· · · · · · · · · ·Q. -- in this legal order?

31· · · · · · · · · ·A. -- the way that this is

32· · presented, yes.

Page 7043·1· · · · · · · · · ·Q. Okay.· You didn't appeal

·2· · that?· You didn't give instructions to appeal

·3· · that order?

·4· · · · · · · · · ·A. No, we did not.

·5· · · · · · · · · ·Q. Okay.· And so is it your

·6· · position today that you had a full

·7· · understanding between October the 5th, 2016,

·8· · and leading up to August the 14th of 2017 of

·9· · what it would take to bring the home into

10· · compliance?

11· · · · · · · · · ·A. We had an understanding we

12· · had done a great deal of work.· We had

13· · weekly -- we developed what's called a Gantt

14· · chart where we had plotted everything that had

15· · to be done.· We had weekly updates of that.· It

16· · was five, six pages long.· It was quite

17· · comprehensive.· So, yes, I think we understood.

18· · · · · · · · · ·Q. Do you agree with me that

19· · what is represented in this order is that there

20· · were deep and longstanding issues of compliance

21· · at the time that the inspectors -- sorry,

22· · longstanding issues of noncompliance at

23· · Caressant Care Woodstock at the time the

24· · inspectors entered the home on October the 5th,

25· · 2016?

26· · · · · · · · · ·A. From October the 5th to this

27· · date, if that's longstanding that this was

28· · contained in this report.

29· · · · · · · · · ·Q. But these issues didn't

30· · happen overnight.· You'll agree with me that

31· · these --

32· · · · · · · · · ·A. I'm going by the reports.

Page 7044·1· · · · · · · · · ·Q. Right.· But these came

·2· · about -- over years, it looks like, based on

·3· · this report?

·4· · · · · · · · · ·A. Well, actually, they were --

·5· · the Ministry was in the building intensively

·6· · for five months.

·7· · · · · · · · · ·Q. Right.· But they're looking

·8· · backwards, right, and when they look backwards,

·9· · they uncover issues that predate the

10· · confessions that existed for a long time and

11· · that were not -- where the home was not in

12· · compliance on a number of issues over a

13· · significant period of time.· You agree?

14· · · · · · · · · ·A. The inspection reports to

15· · that date.· There was some issues.· I wouldn't

16· · say a number of issues.· And the home --

17· · I think we heard a couple of days ago, the home

18· · had always been at a level 1 until this

19· · happened.

20· · · · · · · · · ·Q. I guess somebody wasn't

21· · paying very close attention then.

22· · · · · · · · · ·MS. FRASER:· Thank you very

23· · · · · · · · · ·much.· I have no other

24· · · · · · · · · ·questions.

25· · · · · · · · · ·THE COMMISSIONER:· Thank you.

26· · · · · · · · · ·FURTHER CROSS-EXAMINATION BY MR.

27· · · · · · · · · ·KLOEZE:

28· · · · · · · · · ·Q. Good afternoon, Ms. Hepting.

29· · Do you recall my name is Darrell Kloeze, and

30· · I'm here representing the Ministry, and I

31· · really don't have many questions for you.

32· · · · · · · · · ·One thing that you just raised

Page 7045·1· · with Ms. Fraser, maybe I can clarify this.

·2· · During the time up to at least October 14,

·3· · 2017, you were the most senior person at the

·4· · head office at Caressant Care who was

·5· · responsible for ensuring that Caressant Care

·6· · Woodstock achieved compliance with all these

·7· · outstanding compliance orders; is that correct?

·8· · · · · · · · · ·A. I was the most senior person.

·9· · · · · · · · · ·Q. Okay.

10· · · · · · · · · ·A. There was others on-site that

11· · were more hands-on involved.

12· · · · · · · · · ·Q. From the perspective of the

13· · licensee --

14· · · · · · · · · ·A. Yes.

15· · · · · · · · · ·Q. And we talked last time that

16· · Caressant Care, the corporate head office, is

17· · actually the licensee of the home?

18· · · · · · · · · ·A. Yes.

19· · · · · · · · · ·Q. And the orders are directed

20· · to the licensee; is that correct?

21· · · · · · · · · ·A. That's correct.

22· · · · · · · · · ·Q. And as I understand, your

23· · office, your corporate head office, is just a

24· · couple of blocks away from Caressant Care

25· · Woodstock?

26· · · · · · · · · ·A. That's correct.

27· · · · · · · · · ·Q. One thing you said to

28· · Ms. Fraser is one of these dates -- it may have

29· · been the May date in 2017 when you were in the

30· · home -- you said you didn't go to the home to

31· · check if they were in compliance?

32· · · · · · · · · ·A. No, I said I didn't go to the

Page 7046·1· · home to meet with the inspectors.· They were

·2· · there.· I went for another reason, and I went

·3· · in to speak with them.

·4· · · · · · · · · ·Q. And did you go to the home

·5· · frequently to sort of check up to see how they

·6· · were proceeding with their efforts to achieve

·7· · compliance?

·8· · · · · · · · · ·A. I wouldn't say frequently.

·9· · Most of it was done by telephone contact with

10· · the people at the site.

11· · · · · · · · · ·Q. You talk about -- you

12· · mentioned the example of the tracking tool.

13· · And if you can turn again to page 9.

14· · · · · · · · · ·A. Sorry, and that wasn't May.

15· · It was August.

16· · · · · · · · · ·Q. That was August?

17· · · · · · · · · ·A. Yeah.

18· · · · · · · · · ·Q. Okay.· So let's turn to

19· · page 9 of this report because the tracking tool

20· · comes up a couple times as an example that

21· · Ms. Kukoly raised in her estimation that you

22· · didn't understand or Caressant Care, the

23· · licensee, didn't understand what was required

24· · of them.

25· · · · · · · · · ·If you look at the paragraph of

26· · May 10, 2017, and, again, the VP operations and

27· · the consultant came to the home at different

28· · times to inquire about the progress of the

29· · inspection and were both surprised when

30· · informed by Ministry inspectors there was not

31· · enough evidence to support compliance.

32· · · · · · · · · ·The first bullet point:· [AS

Page 7047·1· · READ]

·2· · · · · · · · · ·"Examples were provided to the

·3· · · · · · · · · ·VP operations of continuing

·4· · · · · · · · · ·noncompliance.· Among them, the

·5· · · · · · · · · ·orders directing that a tracking

·6· · · · · · · · · ·tool be developed to ensure the

·7· · · · · · · · · ·completion of ordered training

·8· · · · · · · · · ·had not been developed and

·9· · · · · · · · · ·training for all staff had not

10· · · · · · · · · ·been completed."

11· · That wasn't the instance where there were just

12· · a couple of names missing from the tracking

13· · tool.· That was an instance where the tracking

14· · tool had not yet even been developed; is that

15· · not correct?

16· · · · · · · · · ·A. That's correct.

17· · · · · · · · · ·Q. So there was an order

18· · requiring Caressant Care to develop a tracking

19· · tool?

20· · · · · · · · · ·A. Well, the home had developed

21· · a binder system of the education that had been

22· · delivered.· What the Ministry was looking for

23· · was a document with a spreadsheet with

24· · everything on that one sheet.

25· · · · · · · · · ·The inspector didn't want to go

26· · through the binder to identify who all -- that

27· · everyone had had the education and their

28· · certificates of attendance were there, their

29· · quizzes, that kind of thing.

30· · · · · · · · · ·Q. So the order required you to

31· · develop a tracking tool, and you gave the

32· · inspector a binder full of sheets?

Page 7048·1· · · · · · · · · ·A. Yes.

·2· · · · · · · · · ·Q. You felt that was sufficient

·3· · as a tracking tool?

·4· · · · · · · · · ·A. Yes.

·5· · · · · · · · · ·Q. So on that occasion, you were

·6· · told that's not sufficient, and we go back to

·7· · the August meeting where you provide the

·8· · tracking tool, but it still doesn't have all

·9· · the names of the staff on it.· Is that what

10· · happened?

11· · · · · · · · · ·A. There was two staffs' names

12· · that weren't on there.

13· · · · · · · · · ·Q. Also in August 2nd, the first

14· · bullet, so we go to the bottom of the page.

15· · Again -- and this was the one, I think, that

16· · Ms. Fraser brought you to, your August 2nd

17· · meeting where you go back to the home, meet

18· · with Ms. Kukoly.· And, again, you were

19· · surprised that the home doesn't have

20· · sufficient -- it has not met compliance yet.

21· · · · · · · · · ·And the example given to you

22· · there by Ms. Kukoly was that the order -- an

23· · order had directed Caressant Care to develop a

24· · quality improvement plan.· Do you see that?

25· · · · · · · · · ·A. Yes.

26· · · · · · · · · ·Q. And the home had not

27· · developed a quality improvement plan?

28· · · · · · · · · ·A. They had developed an action

29· · plan --

30· · · · · · · · · ·Q. An action plan, but that's

31· · different from a quality improvement plan.· The

32· · action plan, as I understand, was dated from

Page 7049·1· · February?

·2· · · · · · · · · ·A. No, no, this was a -- this

·3· · was an action plan specific to this order.

·4· · · · · · · · · ·THE COMMISSIONER:· Specific to

·5· · · · · · · · · ·what?· I didn't --

·6· · · · · · · · · ·THE WITNESS:· To the medication

·7· · · · · · · · · ·administration order.· The

·8· · · · · · · · · ·action plan developed in

·9· · · · · · · · · ·February was to all of the

10· · · · · · · · · ·orders received.

11· · · · · · · · · ·BY MR. KLOEZE:

12· · · · · · · · · ·Q. The inspector found that

13· · whatever you had was not sufficient?

14· · · · · · · · · ·A. She wanted a document

15· · labelled "quality improvement plan," yes.

16· · · · · · · · · ·Q. But it's more than that.· It

17· · wasn't just that it was labelled "quality

18· · improvement plan" at the top.· The inspector

19· · was looking for something quite specific in it?

20· · · · · · · · · ·A. Well, the plan they developed

21· · had the -- had the goals and the strategies and

22· · the responsibilities.· It did not have the

23· · indicators in there that had been asked for in

24· · the quality improvement plan.

25· · · · · · · · · ·Q. We can look at the order.

26· · The order is not before you right now, but we

27· · can look at the order and see what the order

28· · actually required the home to develop.

29· · · · · · · · · ·A. It's okay.· I'm familiar with

30· · it.

31· · · · · · · · · ·Q. And your response to the

32· · inspector at that time was if you went off and

Page 7050·1· · wrote up an action plan or a quality

·2· · improvement plan that afternoon, you asked the

·3· · inspector if that was going to suffice to

·4· · achieve compliance with that aspect of the

·5· · order?

·6· · · · · · · · · ·A. Yes.· If we took the parts of

·7· · the action plan that we had developed --

·8· · I think I actually said that.· You've got the

·9· · parts.· If we put it together, call it a

10· · quality improvement plan, would that suffice.

11· · · · · · · · · ·Q. You had suggested to her

12· · you'd just go off and change the heading to

13· · "quality improvement plan," and you thought

14· · that was going to suffice to achieve

15· · compliance?

16· · · · · · · · · ·A. Basically, yes.

17· · · · · · · · · ·Q. Thank you.

18· · · · · · · · · ·MR. KLOEZE:· Those are all my

19· · · · · · · · · ·questions.· Thank you,

20· · · · · · · · · ·Commissioner.· Thank you,

21· · · · · · · · · ·Ms. Hepting.

22· · · · · · · · · ·RE-EXAMINATION BY MR. GOLDEN:

23· · · · · · · · · ·Q. Ms. Hepting, I just have a

24· · couple of questions for reexamination.· And if

25· · you have in front of you this director's order.

26· · · · · · · · · ·A. Yes.

27· · · · · · · · · ·Q. Ms. Fraser took you to page 6

28· · and asked you some questions about the basis

29· · for the order and all of the noncompliances.

30· · And I'd like to go to that page 6.

31· · · · · · · · · ·And under the heading "Resident

32· · Care Safety," could you read the last line of

Page 7051·1· · the first bullet point, please?

·2· · · · · · · · · ·A. [AS READ]:

·3· · · · · · · · · ·"This order was determined to be

·4· · · · · · · · · ·complied with in May of 2017."

·5· · · · · · · · · ·Q. Did you understand that the

·6· · concern that had been expressed here had been

·7· · resolved and complied with by Caressant Care in

·8· · May of 2017?

·9· · · · · · · · · ·A. Yes.· That order had been put

10· · back into compliance.

11· · · · · · · · · ·Q. Could you go to the next

12· · bullet and read me the last line in the next

13· · bullet?· This was another one that wasn't

14· · brought to your attention.

15· · · · · · · · · ·A. [AS READ]:

16· · · · · · · · · ·"This order was determined to be

17· · · · · · · · · ·complied with in May of 2017."

18· · So it's the same situation.

19· · · · · · · · · ·Q. Could you go down two bullet

20· · points, please.

21· · · · · · · · · ·A. Yes, it's the same.

22· · · · · · · · · ·Q. Could you read me the last

23· · line in this second last bullet point on the

24· · page?

25· · · · · · · · · ·A. [AS READ]:

26· · · · · · · · · ·"This order was determined to be

27· · · · · · · · · ·complied with May 2017."

28· · · · · · · · · ·Q. All right.· Now, let's go

29· · over to the top of page 7 under "Protecting

30· · Residents From Abuse and Neglect."· Could you

31· · look at the first bullet point and read me the

32· · last line in that one?

Page 7052·1· · · · · · · · · ·A. [AS READ]:

·2· · · · · · · · · ·"This order was determined to be

·3· · · · · · · · · ·complied with in May 2017."

·4· · · · · · · · · ·Q. And you were asked some

·5· · questions about did you feel that the home was

·6· · making any progress with these orders.· What

·7· · was your view on that?

·8· · · · · · · · · ·A. I believe we'd made a lot of

·9· · progress in those -- the fact that those orders

10· · were brought into compliance shows that we had.

11· · · · · · · · · ·Q. And, Ms. Hepting, Ms. Fraser

12· · also asked you -- or suggested to you that

13· · there were longstanding problems.

14· · · · · · · · · ·Do you have a recollection of

15· · what the RQI -- the last RQI that was done at

16· · Woodstock before the Wettlaufer confession, do

17· · you have a recollection of that?

18· · · · · · · · · ·A. Yes, because it was done

19· · actually just a couple of weeks before. I

20· · think September -- mid-September it was done.

21· · · · · · · · · ·Q. Did that order have lots of

22· · findings of ongoing problems?

23· · · · · · · · · ·A. No.· We had six WNs.· I think

24· · there was one or two VPCs, I can't remember,

25· · that went with the Ws.· And we did have one

26· · order on not reporting to the director.

27· · · · · · · · · ·MR. GOLDEN:· Thank you.· I have

28· · · · · · · · · ·nothing further.

29· · · · · · · · · ·THE COMMISSIONER:· Thank you.

30· · · · · · · · · ·MS. STEPHENS:· That is it for

31· · · · · · · · · ·that witness.· And so our plan

32· · · · · · · · · ·is to be to start with Natalie

Page 7053·1· · · · · · · · · ·Moroney.

·2· · · · · · · · · · · I note the time.· Perhaps we

·3· · · · · · · · · ·should take the afternoon break

·4· · · · · · · · · ·before.

·5· · · · · · · · · ·THE COMMISSIONER:· Yes.· Let me

·6· · · · · · · · · ·just then -- thank you very

·7· · · · · · · · · ·much, Ms. Hepting.· This means

·8· · · · · · · · · ·you are actually free to go now.

·9· · · · · · · · · ·THE WITNESS:· Thank you.

10· · · · · · · · · ·THE COMMISSIONER:· You're more

11· · · · · · · · · ·than welcome.· All right.

12· · · · · · · · · · · I think it's a good idea for

13· · · · · · · · · ·us.· We'll just get all our

14· · · · · · · · · ·papers in order and so on.

15· · · · · · · · · ·We'll take the afternoon break.

16· · · · · · · · · ·We will come back to begin the

17· · · · · · · · · ·witness, Natalie Moroney.· What

18· · · · · · · · · ·documents do I need on my dais

19· · · · · · · · · ·for that?

20· · · · · · · · · ·MS. STEPHENS:· I think the only

21· · · · · · · · · ·documents that you need are

22· · · · · · · · · ·Ms. Moroney's Affidavit.

23· · · · · · · · · ·THE COMMISSIONER:· Yeah, what

24· · · · · · · · · ·I'll do is I'll keep everything

25· · · · · · · · · ·for Rhonda Kukoly because there

26· · · · · · · · · ·were lots of different documents

27· · · · · · · · · ·there, so I'll have that one,

28· · · · · · · · · ·but should I have anything for

29· · · · · · · · · ·Ms. Simpson, Karen Simpson?

30· · · · · · · · · ·MS. STEPHENS:· I don't think so,

31· · · · · · · · · ·no.

32· · · · · · · · · ·THE COMMISSIONER:· All right.

Page 7054·1· · · · · · · · · ·Okay.

·2· · · · · · · · · ·MS. STEPHENS:· I was planning on

·3· · · · · · · · · ·keeping myself confined to

·4· · · · · · · · · ·what's in the Affidavit with one

·5· · · · · · · · · ·minor exception that I do want

·6· · · · · · · · · ·to speak to counsel about

·7· · · · · · · · · ·briefly on the break.

·8· · · · · · · · · ·THE COMMISSIONER:· All right.

·9· · · · · · · · · ·And there's no chance we'll get

10· · · · · · · · · ·to Ms. Lisa Vink today; right?

11· · · · · · · · · ·MS. STEPHENS:· Not today.

12· · · · · · · · · ·THE COMMISSIONER:· Okay. I

13· · · · · · · · · ·just -- again, because of the

14· · · · · · · · · ·number of documents, I just want

15· · · · · · · · · ·to clean things up a little bit

16· · · · · · · · · ·over the break too.· So we'll

17· · · · · · · · · ·take our recess now.

18· · · · · · · · · ·THE REGISTRAR:· This Public

19· · · · · · · · · ·Inquiry is on recess for 15

20· · · · · · · · · ·minutes.

21· · · · · · · · · ·-- RECESSED AT 3:56 P.M.

22· · · · · · · · · ·-- RESUMED AT 4:12 P.M.

23· · · · · · · · · ·MS. STEPHENS:· Commissioner, at

24· · · · · · · · · ·this time we would like to call

25· · · · · · · · · ·our next witness, Ms. Natalie

26· · · · · · · · · ·Moroney.

27· · · · · · · · · ·THE COMMISSIONER:· Thank you.

28· · · · · · · · · ·Ms. Moroney.

29· · · · · · · · · ·NATALIE CATHERINE MORONEY:

30· · · · · · · · · ·SWORN.

31· · · · · · · · · ·EXAMINATION IN-CHIEF BY MS.

32· · · · · · · · · ·STEPHENS:

Page 7055·1· · · · · · · · · ·Q. So good afternoon, Ms.

·2· · Moroney.

·3· · · · · · · · · ·A. Good afternoon.

·4· · · · · · · · · ·Q. As you know, we have been

·5· · starting most of our witnesses at this Public

·6· · Inquiry by asking whether they have a

·7· · preference to be referred to by their first or

·8· · last name, so I'll start off by asking you what

·9· · your preference is?

10· · · · · · · · · ·A. First name, please.

11· · · · · · · · · ·Q. Okay.· All right, Natalie, so

12· · do you recall swearing an affidavit for the

13· · purpose of this Inquiry?

14· · · · · · · · · ·A. I do.

15· · · · · · · · · ·Q. Okay, there should be a copy

16· · of it right there in front of you.

17· · · · · · · · · ·If I could ask you to please

18· · turn to the final page before tab "A"?

19· · · · · · · · · ·A. Yes.

20· · · · · · · · · ·Q. And if you could confirm, is

21· · that your signature?

22· · · · · · · · · ·A. Yes, it is.

23· · · · · · · · · ·Q. Okay.· Are there any changes

24· · you would like to make to the affidavit at this

25· · time?

26· · · · · · · · · ·A. Yes, at item 38, just a

27· · clarification.

28· · · · · · · · · ·Q. Okay.

29· · · · · · · · · ·A. As it starts "Where we were

30· · advised [...]", the clarification is I did

31· · speak with Arpad Horvath Junior in regards to

32· · not speaking with family.· Any other residents

Page 7056·1· · that were related to Elizabeth Wettlaufer's

·2· · incidents, I did not speak with those family

·3· · members.

·4· · · · · · · · · ·Q. Okay.· Okay, thank you.

·5· · · · · · · · · ·THE COMMISSIONER:· Sorry, at

·6· · · · · · · · · ·paragraph 38?

·7· · · · · · · · · ·BY MS. STEPHENS:

·8· · · · · · · · · ·Q. So it is -- so that would

·9· · be -- so that is the second-last sentence, is

10· · that correct, that currently reads:

11· · · · · · · · · ·"We were advised by Karen not to

12· · · · · · · · · ·contact the families[...]"?

13· · · · · · · · · ·A. Correct.

14· · · · · · · · · ·Q. And so you are telling us

15· · that you did, however, speak with Arpad Horvath

16· · Junior?

17· · · · · · · · · ·A. That's correct.

18· · · · · · · · · ·Q. Okay.

19· · · · · · · · · ·THE COMMISSIONER:· Thank you.

20· · · · · · · · · ·MS. STEPHENS:· So, Commissioner,

21· · · · · · · · · ·with that minor amendment to

22· · · · · · · · · ·that affidavit, I would request

23· · · · · · · · · ·that this be made the next

24· · · · · · · · · ·exhibit at the hearing.

25· · · · · · · · · ·THE COMMISSIONER:· Yes, thank

26· · · · · · · · · ·you.· So I believe I'm right,

27· · · · · · · · · ·Madam Clerk, Exhibit 142?

28· · · · · · · · · ·THE COURT CLERK:· That's

29· · · · · · · · · ·correct.

30· · · · · · · · · ·THE COMMISSIONER:· Thank you,

31· · · · · · · · · ·the Affidavit of Natalie

32· · · · · · · · · ·Moroney.

Page 7057·1· · · · · · · · · ·EXHIBIT NO. 142:· Affidavit of

·2· · · · · · · · · ·Natalie Moroney, sworn July 24,

·3· · · · · · · · · ·2018.

·4· · · · · · · · · ·BY MS. STEPHENS:

·5· · · · · · · · · ·Q. All right, Natalie.· So I

·6· · understand you have been a Registered Nurse

·7· · since 2005?

·8· · · · · · · · · ·A. Yes.

·9· · · · · · · · · ·Q. And before that, you were

10· · actually an RPN having graduated from St. Clair

11· · College in 1998?

12· · · · · · · · · ·A. Yes.

13· · · · · · · · · ·Q. Okay, so you have been

14· · working as a nurse for awhile.

15· · · · · · · · · ·And I understand from your

16· · affidavit that you have spent several years,

17· · many years working in long-term care before

18· · joining the Ministry of Health; is that

19· · correct?

20· · · · · · · · · ·A. That's correct.

21· · · · · · · · · ·Q. And in that capacity, you

22· · have worked as a Charge Nurse?

23· · · · · · · · · ·A. Yes.

24· · · · · · · · · ·Q. And you also worked as an

25· · Associate Director of Care?

26· · · · · · · · · ·A. Yes.

27· · · · · · · · · ·Q. And a RAI Coordinator?

28· · · · · · · · · ·A. Yes.

29· · · · · · · · · ·Q. And also a Director of Care?

30· · · · · · · · · ·A. Yes.

31· · · · · · · · · ·Q. Okay.· And in fact, I

32· · understand that between 2006 and 2008, you were

Page 7058·1· · first the Associate Director of Care and then

·2· · the Director of Care at Meadow Park London;

·3· · correct?

·4· · · · · · · · · ·A. Yes.

·5· · · · · · · · · ·Q. And you joined the Ministry

·6· · in December 2014 at the London Service Area

·7· · Office; correct?

·8· · · · · · · · · ·A. Yes.

·9· · · · · · · · · ·Q. Okay.· So when you joined the

10· · Ministry, was there any concern or was there

11· · ever any concern when you become an Inspector

12· · about going back to the homes that you had

13· · worked in previously in management in

14· · conducting inspections there?

15· · · · · · · · · ·A. As a Nursing Inspector, if

16· · the individual nurse had concerns about

17· · returning to the home, those -- that Inspector

18· · could voice those concerns.· Otherwise, there

19· · would be no reason not to go back to the home

20· · unless there was concerns that the Inspector

21· · themselves felt uncomfortable.

22· · · · · · · · · ·Q. Okay.· And we know you are

23· · here today to talk to us about the inspection

24· · that you conducted at Meadow Park London in

25· · relation to Elizabeth Wettlaufer's confessions.

26· · Was there any concern raised about doing that

27· · inspection in a home where you had once worked?

28· · · · · · · · · ·A. No, there was not.

29· · · · · · · · · ·Q. Okay.· Had you conducted

30· · inspections at Meadow Park prior to this

31· · inspection in October of 2016?

32· · · · · · · · · ·A. Yes, I have.

Page 7059·1· · · · · · · · · ·Q. Okay.· So, Natalie, we have

·2· · heard a lot of evidence today and yesterday

·3· · from Rhonda about the nuts and bolts of

·4· · conducting inspections, so I don't intend to

·5· · cover that same ground with you today.

·6· · · · · · · · · ·But I do want to focus in on

·7· · that inspection at Meadow Park that you were

·8· · assigned to in the fall of 2016.

·9· · · · · · · · · ·So we heard from both Karen and

10· · Rhonda earlier this week that you and Rhonda

11· · ended up being assigned to work on those

12· · inspections on October 5th, 2016; correct?

13· · · · · · · · · ·A. Yes.

14· · · · · · · · · ·Q. And so that happened.· You

15· · were in the office and your Manager, Peggy

16· · Skipper, called you in?

17· · · · · · · · · ·A. Our ITL actually at that time

18· · called us into Peggy Skipper's office.

19· · · · · · · · · ·Q. Okay.

20· · · · · · · · · ·A. And when we sat down, we were

21· · provided an email to read.· The email was

22· · from -- I believe it was from OLTCA, and it was

23· · in regards to a nurse that had confessed at

24· · that time to murders.

25· · · · · · · · · ·Q. Okay.· And when you said you

26· · were called in by the ITL, that is the

27· · Inspector Team Lead?

28· · · · · · · · · ·A. Right, at that time we had

29· · Inspection Team Leads.

30· · · · · · · · · ·Q. Okay.· So that was the email.

31· · Have you been here this week for the testimony?

32· · Did you see the email that Ms. Simpson was

Page 7060·1· · asked about?

·2· · · · · · · · · ·A. I did see that.

·3· · · · · · · · · ·Q. Okay, so is that the email

·4· · that you are talking about?

·5· · · · · · · · · ·A. Yes.

·6· · · · · · · · · ·Q. Okay.· So we know from

·7· · Rhonda's testimony and from your affidavit that

·8· · you went to Caressant Care that same day to

·9· · speak to the Administrator and get

10· · documentation; is that right?

11· · · · · · · · · ·A. Yes, we did.

12· · · · · · · · · ·Q. Okay.· And later that night,

13· · Rhonda called you to advise you that Peggy

14· · Skipper had learned about the fact that

15· · Elizabeth Wettlaufer had also worked at Meadow

16· · Park and that you would need to go to that home

17· · the next morning; is that right?

18· · · · · · · · · ·A. Yes.

19· · · · · · · · · ·Q. Okay.· So I want you to start

20· · by telling us about your visit to Meadow Park

21· · on October 6th, 2016, and what happened when

22· · you got to that home?

23· · · · · · · · · ·A. We were given the same

24· · direction that we had been given when we went

25· · to Caressant Care Woodstock the day before,

26· · that we would only speak to the Administrator

27· · at Meadow Park London, that we would ask for

28· · the HR file for Elizabeth Wettlaufer, and at

29· · that time the home had submitted a Critical

30· · Incident Report but it didn't identify the

31· · resident.

32· · · · · · · · · ·When we went to Meadow Park

Page 7061·1· · London, the Administrator at that time provided

·2· · us with the name of Arpad Horvath.· That was

·3· · one of the murder victims of Elizabeth

·4· · Wettlaufer.· She had learned that from the

·5· · detectives who had been in the home earlier

·6· · that week.

·7· · · · · · · · · ·Q. Okay.

·8· · · · · · · · · ·A. The documentation from Meadow

·9· · Park London was already prepared for us to pick

10· · up, so we did receive the HR file at that time

11· · and Arpad Horvath's health care records, as

12· · well as I believe Elizabeth Wettlaufer's

13· · schedule and any shifts she had worked during

14· · that time.

15· · · · · · · · · ·Q. Okay.· And the HR file, that

16· · was Elizabeth Wettlaufer's HR file?

17· · · · · · · · · ·A. Yes, it was.

18· · · · · · · · · ·Q. Okay.· So we know from both

19· · Karen and Rhonda that you don't actually return

20· · to Meadow Park or to any of the homes to start

21· · investigating for until about three weeks

22· · later.· Can you tell us a bit about the record

23· · review that you did in preparing to return to

24· · the home?

25· · · · · · · · · ·A. We reviewed, myself and

26· · another Inspector, Neil Kikuta, we did review

27· · Elizabeth Wettlaufer's HR file.· Inside the

28· · file, there was documentation related to

29· · reference checks.· There was a letter of

30· · reference from Caressant Care Woodstock.

31· · · · · · · · · ·We reviewed any of her shifts

32· · that she would have worked around the time, if

Page 7062·1· · there was any deaths in the home, so we also

·2· · had the Coroners -- or not the Coroners, but

·3· · the Death Registry information with us.

·4· · · · · · · · · ·Our AAs did prepare a

·5· · spreadsheet with any deaths that had occurred

·6· · around Elizabeth Wettlaufer's days that she had

·7· · worked in the home.

·8· · · · · · · · · ·Q. So was that similar to what

·9· · Rhonda was telling us about that had been

10· · prepared with respect to Caressant Care?

11· · · · · · · · · ·A. That's right.

12· · · · · · · · · ·Q. Okay.

13· · · · · · · · · ·A. We reviewed any critical

14· · incidents at that time that were -- that had

15· · not yet been inspected upon, so they might have

16· · been from in the intake system for the CISC

17· · server.

18· · · · · · · · · ·Q. So these were outstanding

19· · intakes for the home?

20· · · · · · · · · ·A. Not necessarily outstanding,

21· · because they were from 2016.

22· · · · · · · · · ·Q. Okay.· What I meant by

23· · "outstanding" was intakes that had not yet been

24· · inspected?

25· · · · · · · · · ·A. Yes, correct.

26· · · · · · · · · ·Q. So that is what you were

27· · looking at.· Did you also look at Critical

28· · Incident Reports received in relation to Meadow

29· · Park, whether in relation to Mr. Horvath, the

30· · victim, or anything received in relation to Ms.

31· · Wettlaufer?

32· · · · · · · · · ·A. We did review our CIS server

Page 7063·1· · for any relation to Elizabeth Wettlaufer and

·2· · anything related to Arpad Horvath.· There was

·3· · also other inspections that had already been

·4· · previously inspected that we did review.

·5· · · · · · · · · ·Q. So one of the things that you

·6· · mention is the letter of reference that you

·7· · found in that file.· You indicate in your

·8· · affidavit that you were surprised by that.· Can

·9· · you explain that to us?

10· · · · · · · · · ·A. In conversation with Rhonda

11· · Kukoly and reviewing the health care records,

12· · it was found that she had -- Elizabeth

13· · Wettlaufer had several different types of

14· · medication incidents and medication incidents

15· · that did cause adverse reactions to residents.

16· · · · · · · · · ·There had been absentee

17· · concerns, and then also as well there was

18· · concerns regarding co-workers within the home.

19· · · · · · · · · ·So to read the letter of

20· · reference, it was a bit surprising to me.

21· · · · · · · · · ·Q. And just unpack that for me a

22· · little bit, a bit surprising.· Was it because

23· · it was based on what you had seen in -- or what

24· · you had heard from Rhonda about Caressant Care?

25· · · · · · · · · ·A. Well, and my understanding

26· · was Elizabeth Wettlaufer had been terminated

27· · because of those medication incidents.

28· · · · · · · · · ·Q. Okay.· And at that time, was

29· · it clear to you that Meadow Park knew she was

30· · terminated, she had been terminated?

31· · · · · · · · · ·A. It was not clear to me at

32· · that time.

Page 7064·1· · · · · · · · · ·Q. So I understand that you also

·2· · reviewed the compliance history for Meadow

·3· · Park?

·4· · · · · · · · · ·A. We did in this inspection.

·5· · We wouldn't normally do that for other

·6· · inspections.

·7· · · · · · · · · ·Q. Okay, and what do you mean by

·8· · that?· Because I had understood you would

·9· · always pull the 36-month compliance history

10· · prior to going into the home.

11· · · · · · · · · ·A. If we are going into the home

12· · and we are looking at the compliance, we are

13· · not -- we are taking the compliance history

14· · with us when we go into the home.· We might not

15· · necessarily look at that compliance history

16· · until the inspection is complete in the home

17· · and we are sitting down and we are reviewing

18· · the matrix, and that would be the time that the

19· · compliance history over three years would be

20· · reviewed.

21· · · · · · · · · ·Q. Okay.· But so this time you

22· · actually did look at it?

23· · · · · · · · · ·A. We did.

24· · · · · · · · · ·Q. And was there anything in

25· · particular that stood out to you?

26· · · · · · · · · ·A. At that time, no.

27· · · · · · · · · ·Q. Okay.· Now, did you consider

28· · at all, did you look at all at the risk level

29· · or performance level that had been assigned to

30· · Meadow Park before going into that inspection?

31· · · · · · · · · ·A. No, I did not.

32· · · · · · · · · ·Q. Is that something that you

Page 7065·1· · would typically do before an inspection?

·2· · · · · · · · · ·A. No, we don't.

·3· · · · · · · · · ·Q. Okay.· All right, so anything

·4· · else that you did prior to going into the home

·5· · to starting your on-site inspection?

·6· · · · · · · · · ·A. I was not present when the

·7· · plan was created.· Rhonda and Lisa created the

·8· · plan.· I did have an opportunity to review the

·9· · plan --

10· · · · · · · · · ·Q. Okay.

11· · · · · · · · · ·A. -- and so did Neil, so we

12· · were allowed to provide feedback into that

13· · plan.

14· · · · · · · · · ·Q. Okay.

15· · · · · · · · · ·A. There wasn't -- the critical

16· · incidences that we took with us in the home, we

17· · did review those.

18· · · · · · · · · ·Q. Okay.

19· · · · · · · · · ·A. And we did ensure that we --

20· · there was no other critical incidents or

21· · complaints that were related to Arpad Horvath.

22· · · · · · · · · ·Q. Okay.· All right, so you and

23· · your co-Inspector, Neil Kikuta, go to Meadow

24· · Park towards the end of October 2016.· I want

25· · you to just walk us through the inspections,

26· · but at this stage I am more interested in the

27· · process, the things that you did.

28· · · · · · · · · ·We are going to get into --

29· · we'll go through the report and talk about the

30· · findings in more detail, but talk to us about

31· · the steps you took in that inspection.

32· · · · · · · · · ·A. Okay, we did arrive at the

Page 7066·1· · home on October 28th.· We were given direction

·2· · from Karen Simpson to only speak with the

·3· · Administrator at that time.

·4· · · · · · · · · ·We had -- when we arrived at the

·5· · home, we had asked the Administrator for any

·6· · critical incidents that we had brought with us,

·7· · any internal investigation notes.· We also

·8· · asked for the complaint binder, the abuse

·9· · policy, any medication incidents.

10· · · · · · · · · ·Q. Now, you say --

11· · · · · · · · · ·A. And I believe the medication

12· · policy as well.

13· · · · · · · · · ·Q. Okay, and you say you asked

14· · about an CIs you brought.· Can you tell us how

15· · many Critical Incident Reports you had brought

16· · along?

17· · · · · · · · · ·A. I'm not exactly sure I know.

18· · In total we had 14, but some were assigned to

19· · us during the inspection.

20· · · · · · · · · ·Q. Okay.· And so you had

21· · mentioned -- did you have Arpad Horvath's

22· · medical records before you started the

23· · inspection or --

24· · · · · · · · · ·A. We had --

25· · · · · · · · · ·Q. -- did you get those when the

26· · inspection started?

27· · · · · · · · · ·A. Sorry, we had the health care

28· · records of Arpad Horvath.· There would have

29· · been -- so one of the things that we did not

30· · acquire at that time I believe it was the

31· · medication administration, which was the eMAR.

32· · · · · · · · · ·Q. Okay.

Page 7067·1· · · · · · · · · ·A. So that is the digital eMAR.

·2· · · · · · · · · ·Q. Okay.

·3· · · · · · · · · ·A. And I wasn't sure when the

·4· · home had flipped from documentation from paper

·5· · documentation to digital.

·6· · · · · · · · · ·Q. Okay.· So when you got to the

·7· · home, you also had access to the eMAR?

·8· · · · · · · · · ·A. We had access to PCC, which

·9· · is Point Click Care, where that information is

10· · stored.

11· · · · · · · · · ·Q. Okay.· And just taking a step

12· · back, had there been anything that you had

13· · noticed in Arpad Horvath's records prior to

14· · going into the inspection that raised any alarm

15· · bells or made you think we need to look into

16· · that?

17· · · · · · · · · ·A. We were looking at the

18· · specific care that Elizabeth Wettlaufer had

19· · provided, so again, the Progress Notes

20· · documentation in regards to Arpad, which is --

21· · I don't know if you want me to go there now or

22· · not, but for the -- when he was -- there was

23· · documentation that showed Arpad had been tied

24· · to his bed rail by his jogging pants.

25· · · · · · · · · ·Q. Okay, and that ultimately

26· · ends up being one of the -- some of the

27· · evidence to support a finding of

28· · non-compliance; correct?

29· · · · · · · · · ·A. Correct, yes.

30· · · · · · · · · ·Q. Okay, so we'll get into that

31· · in more detail.

32· · · · · · · · · ·A. Uhm-hmm.

Page 7068·1· · · · · · · · · ·Q. But you had -- so that was

·2· · something you had noticed in your review of the

·3· · records beforehand?

·4· · · · · · · · · ·A. Correct.

·5· · · · · · · · · ·Q. So when you first get into

·6· · the home and you are going through these

·7· · records, what were you looking for in those

·8· · records?· You had talked about a bunch of

·9· · different things.

10· · · · · · · · · ·A. When we first entered the

11· · home and were still -- we actually did not

12· · start investigating into Arpad Horvath at that

13· · time.· We did start looking into the Medication

14· · IP, and we were directed at that time to

15· · complete the Medication IP in its entirety.

16· · · · · · · · · ·So we actively started that

17· · inspection in the home.

18· · · · · · · · · ·Q. Okay.· Let me pause there for

19· · a second.

20· · · · · · · · · ·A. Yes.

21· · · · · · · · · ·Q. So we understand that that

22· · was really -- we have heard from both Karen and

23· · Rhonda that that was really the first time that

24· · Inspectors had been asked to do that Medication

25· · IP in its entirety, and we now know that this

26· · is routinely done in RQIs.

27· · · · · · · · · ·So before we talk about the

28· · Meadow Park specific inspection on the

29· · Medication IP, I wanted to ask you, as I did

30· · Rhonda, about what you have been finding

31· · generally in other homes when you have been

32· · inspecting on those new parts that you are

Page 7069·1· · inspecting on in the Medication IPs?

·2· · · · · · · · · ·A. The newer part of it, 135,

·3· · if we could pull up that legislation or I could

·4· · open it?

·5· · · · · · · · · ·Q. Sure.· I of course do not

·6· · have my reference to it at my fingertips.· It

·7· · is going to be in the legislative brief, which

·8· · is Exhibit 5, I believe; am I right?· Can

·9· · anyone confirm for me that that's Exhibit 5?

10· · · · · · · · · ·Yes, okay, and section 135

11· · should be on page 1126.

12· · · · · · · · · ·MS. STEPHENS:· So, Commissioner,

13· · · · · · · · · ·as we are pulling this up, I

14· · · · · · · · · ·realize I forgot to request your

15· · · · · · · · · ·permission.

16· · · · · · · · · · · Natalie, like Rhonda and

17· · · · · · · · · ·Karen, has a copy of the Act in

18· · · · · · · · · ·paper copy before her, a clean

19· · · · · · · · · ·copy.· Would it be okay if she

20· · · · · · · · · ·refers to that in her evidence?

21· · · · · · · · · ·THE COMMISSIONER:· Of course.

22· · · · · · · · · ·BY MS. STEPHENS:

23· · · · · · · · · ·Q. Okay, if she prefers that to

24· · the screen, you may do so, but it is also up

25· · here for everyone to see.

26· · · · · · · · · ·Okay, so there is section 135.

27· · · · · · · · · ·A. So again, under 1 of section

28· · 135 is:

29· · · · · · · · · ·"Every licensee of a long-term

30· · · · · · · · · ·care home shall ensure that

31· · · · · · · · · ·every medication incident

32· · · · · · · · · ·involving a resident and every

Page 7070·1· · · · · · · · · ·adverse drug reaction is,"

·2· · · · · · · · · ·And then it breaks it down.

·3· · · · · · · · · ·In our concurrent inspections

·4· · that we have been completing, we have found

·5· · that the homes, although they are trying their

·6· · best, that at times 135 is not completed in its

·7· · entirety, so the actions might not have been

·8· · completed or the analysis.

·9· · · · · · · · · ·There was also the notification

10· · to the families, the physician, the pharmacies,

11· · and that those records are kept.

12· · · · · · · · · ·Q. Okay.· And you mention in the

13· · final paragraph of your affidavit that you have

14· · concerns that the new focus at looking at

15· · medication incidents may actually be leading

16· · staff not to report medication incidents.

17· · · · · · · · · ·Could you explain what you mean

18· · by that?

19· · · · · · · · · ·A. So every nurse -- if they are

20· · being truthful, nurses are being truthful, they

21· · are self-reporting themselves or they are

22· · self-reporting their co-workers when there is a

23· · medication incident and they are coming

24· · forward.

25· · · · · · · · · ·Under section 135, we also have

26· · giving medication as prescribed, so the

27· · administration of medication is being given as

28· · prescribed.

29· · · · · · · · · ·If a medication incident shall

30· · occur in the home, we are also leaving findings

31· · under 131.

32· · · · · · · · · ·For those staff currently, the

Page 7071·1· · home does speak with the resident -- if the

·2· · home is doing everything that they can without

·3· · scrutiny under 131, they have done everything,

·4· · they have spoke to the nurse, they have

·5· · followed up with the family, there was no

·6· · adverse drug reaction to the resident, and we

·7· · are still leaving issues for findings under

·8· · 131, the homes are feeling that the registered

·9· · staff may not want to report these medication

10· · incidents further.

11· · · · · · · · · ·And on top of that, we are going

12· · into the home and we are inspecting on these

13· · issues and that we want the registered staff to

14· · feel comfortable with us, because they are

15· · telling us the truth and they are telling the

16· · home the truth.

17· · · · · · · · · ·So that is what I meant.

18· · · · · · · · · ·Q. Okay.· So let's talk about,

19· · because when you were at Meadow Park, it was

20· · the first time that you were inspecting on the

21· · Medication IP in its entirety?

22· · · · · · · · · ·A. Uhm-hmm.

23· · · · · · · · · ·Q. Can you tell us what you did?

24· · What were the steps that you took in relation

25· · to that?

26· · · · · · · · · ·A. On October 28th, we started

27· · to observe the medication rooms where the

28· · medication carts were stored in one area of the

29· · home.

30· · · · · · · · · ·The medication carts have

31· · drawers, as Rhonda was explaining, that pull

32· · out, and inside those drawers there are

Page 7072·1· · individually labelled narcotic -- or sorry,

·2· · medication strips, and on those strips there is

·3· · personal health information related to the

·4· · resident and what medications that resident

·5· · will be taking.

·6· · · · · · · · · ·As well, in the medication carts

·7· · there is a locked controlled substance box

·8· · which is usually separate from the resident's

·9· · medication, but it is in the bottom of the cart

10· · and it is also locked.

11· · · · · · · · · ·When we had observed the

12· · medication cart in the very first med room, we

13· · had noticed that there was Hydromorphone

14· · ampules that had been opened; there was two in

15· · the top shelf of the medication cart, where

16· · they were supposed to be stored in a locked

17· · area.

18· · · · · · · · · ·There was also medication that

19· · were in Dixie cups, so when the medication is

20· · being poured for the residents and provided to

21· · the resident, they were not in the original

22· · packaging that was sent from the pharmacy and

23· · they had no client identifiers as to who was to

24· · receive those medications.

25· · · · · · · · · ·The home is to complete -- when

26· · a Registered Nurse is coming on shift and a

27· · nurse is leaving the shift, there is supposed

28· · to be a count that is completed on each shift

29· · of controlled substances, and those controlled

30· · counts are supposed to be signed by the nurse

31· · coming on shift and the nurse coming off the

32· · shift once the controlled count is complete.

Page 7073·1· · · · · · · · · ·And we noticed that there was

·2· · deficiencies within those count sheets where

·3· · staff had not signed that they had counted the

·4· · shift counts together.

·5· · · · · · · · · ·The medication records from the

·6· · pharmacy, so if the registered staff had

·7· · ordered a medication, there was a pharmacy

·8· · order book where those stickers would be pulled

·9· · from the medication and placed into the books.

10· · Pharmacy then would receive those medication

11· · lifts by fax from the home, and the pharmacy

12· · would deliver the medication to the home.· The

13· · registered staff would then sign in those

14· · medications.

15· · · · · · · · · ·As we flipped back over 30 days,

16· · we noticed that there was several medications

17· · that had not been signed for, and I later found

18· · out, after speaking with the Administrator,

19· · that they were received in the home.

20· · · · · · · · · ·There was large drug destruction

21· · bins within the one medication room of

22· · non-controlled substances.· Normally, they

23· · would be de-natured, the medication would be

24· · de-natured in the large bins, and usually there

25· · is a top that is screwed on top of these white

26· · very large containers.

27· · · · · · · · · ·The containers that we observed

28· · were large, full.· There was ampules in there,

29· · needles and medication that required to be

30· · de-natured, and there was no lid on these

31· · buckets as well.

32· · · · · · · · · ·THE COMMISSIONER:· I couldn't

Page 7074·1· · · · · · · · · ·hear you.

·2· · · · · · · · · ·THE WITNESS:· Sorry.

·3· · · · · · · · · ·THE COMMISSIONER:· And so they

·4· · · · · · · · · ·were required to be de-natured.

·5· · · · · · · · · ·What did you say after that?

·6· · · · · · · · · ·THE WITNESS:· And there should

·7· · · · · · · · · ·be a lid on the bucket as well.

·8· · · · · · · · · ·BY MS. STEPHENS:

·9· · · · · · · · · ·Q. And there was no lid on it?

10· · · · · · · · · ·A. And there was no lid.

11· · · · · · · · · ·Q. Okay, and would they

12· · normally -- and I think you said there were

13· · needles in --

14· · · · · · · · · ·A. Yes, so that normally for

15· · dispensing sharps, there is a sharps container

16· · within the medication room that -- or on the

17· · medication carts that they would dispense

18· · sharps.

19· · · · · · · · · ·Q. Okay.

20· · · · · · · · · ·A. In another area of the home,

21· · for the second med room medication observation

22· · we noticed that there had been medication

23· · received within the home that was not labelled,

24· · so there was no resident personal health

25· · information.

26· · · · · · · · · ·And there were insulin pens with

27· · no client identifiers, again no label from the

28· · pharmacy, or they were illegible, you couldn't

29· · read what pen was for who.

30· · · · · · · · · ·Q. And all medication in the

31· · home normally would have to be labelled and

32· · specific to a particular resident?

Page 7075·1· · · · · · · · · ·A. It would have the specific --

·2· · it would have the name, the date, the dose, the

·3· · prescription number very clearly identified on

·4· · the pens.

·5· · · · · · · · · ·Q. Okay, and so did you also --

·6· · so that was -- was that your first day in the

·7· · home that you were seeing --

·8· · · · · · · · · ·A. That was the first day.

·9· · · · · · · · · ·Q. Okay.

10· · · · · · · · · ·A. And what was a little bit

11· · different for us on the first day was that we

12· · could not speak to the registered staff.

13· · · · · · · · · ·So normally, when we are

14· · completing these observations, we would go

15· · directly to the registered staff that would be

16· · responsible for that medication cart.· And in

17· · these observations, we had to have the

18· · Administrator come and observe and explain and

19· · then have her talk to her registered staff and

20· · kind of tell us what was happening.

21· · · · · · · · · ·So that was a different process

22· · for us, because normally we can speak to anyone

23· · and we can have that information quite quickly.

24· · · · · · · · · ·Q. Okay.· So you were going

25· · through the Administrator and asking her

26· · questions?

27· · · · · · · · · ·A. Yes, that's correct.

28· · · · · · · · · ·Q. And who was the Administrator

29· · at that time?

30· · · · · · · · · ·A. Nicole Ross.

31· · · · · · · · · ·Q. Okay.· And so what other

32· · steps did you take in relation to the

Page 7076·1· · Medication Inspection Protocol and inspecting

·2· · in relation to that?

·3· · · · · · · · · ·A. We did have a conversation

·4· · with Peggy Skipper from the London SAO as well

·5· · as Karen Simpson in regards to the concerns

·6· · that we had found in the home just in the one

·7· · day regarding medication management.

·8· · · · · · · · · ·Q. Okay.

·9· · · · · · · · · ·A. The home has four medication

10· · rooms in total.· There was other areas where

11· · medication packages where medication was

12· · required to be de-natured in these medication

13· · rooms as well that had not.

14· · · · · · · · · ·It wasn't until I believe

15· · November 3rd when we could speak with the staff

16· · that we were able to identify why these things,

17· · so that we could answer our who, what, when,

18· · where and why, because at that time we could

19· · not.

20· · · · · · · · · ·Q. Okay, and sorry what date was

21· · that, November --

22· · · · · · · · · ·A. I believe that was November

23· · 3rd.

24· · · · · · · · · ·Q. Okay.· And in terms of what

25· · you were seeing, I think everything that you

26· · have talked about so far, checking on drug

27· · storage, looking at things in the medication

28· · cart, that would be what you would often

29· · inspect upon as part of the Medication IP?

30· · · · · · · · · ·A. That's correct.

31· · · · · · · · · ·Q. So was it unusual what you

32· · were seeing in this home?

Page 7077·1· · · · · · · · · ·A. Being that it was a

·2· · widespread issue, that it was in all areas --

·3· · medication -- there was medication concerns in

·4· · all areas of the home, so there was four

·5· · medication rooms.

·6· · · · · · · · · ·Q. Okay.· So being that it was

·7· · widespread, it did surprise you or was it --

·8· · was this unusual?

·9· · · · · · · · · ·A. Being that we were completing

10· · the IP in its entirety and there was areas that

11· · we might have not always inspected upon, I

12· · can't necessarily say it was surprising,

13· · because I had not inspected in those areas

14· · before.· So if it was related to -- we wouldn't

15· · necessarily go and look at non-controlled

16· · substances unless our evidence took us there.

17· · · · · · · · · ·Q. Okay, and did you -- we heard

18· · from Rhonda about observing medication

19· · administration.· Did you do that as well?

20· · · · · · · · · ·A. Yes, we did that as well.

21· · · · · · · · · ·Q. So you said you began your

22· · interviews on November 3rd?

23· · · · · · · · · ·A. Uhm-hmm.

24· · · · · · · · · ·Q. And can you tell us a bit

25· · about that?

26· · · · · · · · · ·A. Well, we started our

27· · interviews on November 3rd, but I believe it

28· · was either the same day or the next day that we

29· · had to stop our interviews and that we were

30· · told that there would be legal representation

31· · for staff in the home if we wanted to conduct

32· · the interviews.

Page 7078·1· · · · · · · · · ·So I believe we had stopped at

·2· · that time, and we did call Karen Simpson and

·3· · had a conversation with her for directions on

·4· · how to continue.

·5· · · · · · · · · ·Q. Okay.

·6· · · · · · · · · ·A. Any issues that were related

·7· · to 2014 within the home or any non-compliances

·8· · or concerns that we had, in order to speak to

·9· · the staff, we would need to have legal

10· · representation present.

11· · · · · · · · · ·Q. Okay.

12· · · · · · · · · ·A. Anything related to current

13· · issues in the home did not require legal

14· · representation.

15· · · · · · · · · ·Q. So the concurrent inspections

16· · that you had brought along, the CI

17· · complaints -- or the CIs, did you bring along

18· · complaints as well or --

19· · · · · · · · · ·A. We had complaints with us as

20· · well.

21· · · · · · · · · ·Q. Okay, so those concurrent

22· · inspections that were for the current period,

23· · you could interview --

24· · · · · · · · · ·A. Yes, we could.

25· · · · · · · · · ·Q. -- the individuals associated

26· · with that?

27· · · · · · · · · ·A. Right.

28· · · · · · · · · ·Q. It was just the ones from

29· · 2014 --

30· · · · · · · · · ·A. 2014.

31· · · · · · · · · ·Q. Okay.

32· · · · · · · · · ·THE REPORTER:· Ms. Stephens, I'm

Page 7079·1· · · · · · · · · ·sorry, I'm having trouble

·2· · · · · · · · · ·hearing you when you step away

·3· · · · · · · · · ·from the mic, and also, there is

·4· · · · · · · · · ·some overlap between yourself

·5· · · · · · · · · ·and the witness.

·6· · · · · · · · · ·BY MS. STEPHENS:

·7· · · · · · · · · ·Q. Okay, I'm sorry.

·8· · · · · · · · · ·Okay, so just to be clear, so

·9· · you were allowed to conduct, to do interviews

10· · in relation to the concurrent inspections you

11· · had brought along?

12· · · · · · · · · ·A. Correct.

13· · · · · · · · · ·Q. But not in relation to really

14· · the Elizabeth Wettlaufer issues from 2014?

15· · · · · · · · · ·A. Yes.

16· · · · · · · · · ·Q. Okay.· So what happened with

17· · that?· So you held off a bit, but you

18· · ultimately do conduct those interviews?

19· · · · · · · · · ·A. We did -- we held off.· We

20· · completed our -- with medication, completing

21· · the Medication IP, as well as reviewing the

22· · critical incidents in the home that we had with

23· · us at that time.

24· · · · · · · · · ·We had to schedule and

25· · coordinate, which is again a bit different and

26· · unusual for us to have to schedule and

27· · coordinate interviews with staff, so that

28· · process was a bit slower.

29· · · · · · · · · ·Q. Okay.

30· · · · · · · · · ·A. But we did continue to

31· · conduct inspections for 2016.

32· · · · · · · · · ·Q. Okay.· And so can you tell us

Page 7080·1· · how long you were on-site at Meadow Park

·2· · conducting this inspection?

·3· · · · · · · · · ·A. This was from October until

·4· · March.

·5· · · · · · · · · ·Q. October until March, okay.

·6· · · · · · · · · ·So we know from Karen's

·7· · testimony on Monday that before your final

·8· · Inspection Report was issued, there were some

·9· · immediate orders that were issued against

10· · Meadow Park; is that correct?

11· · · · · · · · · ·A. There were orders issued,

12· · yes.

13· · · · · · · · · ·Q. Okay.

14· · · · · · · · · ·So, Laura, I would like to pull

15· · up these orders.

16· · · · · · · · · ·Natalie and Commissioner, you'll

17· · find the orders that we are talking about or

18· · that I would like to talk about at Exhibit "B"

19· · to the affidavit.· And, Laura, the document ID

20· · number is 40984.

21· · · · · · · · · ·So if we could just scroll down

22· · a little bit, so I understand that this was a

23· · Compliance Order and this is -- is this the

24· · Order Report and it went out on February 6th,

25· · 2017?

26· · · · · · · · · ·A. Yes.

27· · · · · · · · · ·Q. Okay.· Now, was your

28· · inspection done at that time, or you were

29· · still --

30· · · · · · · · · ·A. No, we were still -- yes,

31· · sorry, we were still actively inspecting in the

32· · home.

Page 7081·1· · · · · · · · · ·Q. Okay, and the police

·2· · investigation was still ongoing?

·3· · · · · · · · · ·A. Yes.

·4· · · · · · · · · ·Q. Okay.· So we know this order

·5· · was framed really as an order in its entirety

·6· · relating to section 114 of the regulation; is

·7· · that right?

·8· · · · · · · · · ·A. Uhm-hmm.

·9· · · · · · · · · ·Q. And you say in your affidavit

10· · and Karen told us that that was at the

11· · Director's direction?

12· · · · · · · · · ·A. Yes, it was.

13· · · · · · · · · ·Q. Okay.· So if we could turn to

14· · page 2, and we'll just scroll down, so these

15· · are the terms of the order; is that correct?

16· · These were the steps that you wanted Meadow

17· · Park to undertake; is that right?

18· · · · · · · · · ·A. Yes.

19· · · · · · · · · ·Q. So can you just tell us what

20· · they needed to do, what the problems were?

21· · · · · · · · · ·A. A few of the concerns that we

22· · did learn in the home is that the policies and

23· · procedures were not well understood.· The home

24· · was going through a transition period from

25· · Classic Care Pharmacy to Silver Fox Pharmacy,

26· · and the home had their own policies as well.

27· · · · · · · · · ·In interviews with the staff,

28· · they weren't really clear on what policies they

29· · were supposed to be following and what

30· · procedures they were to be completing.

31· · · · · · · · · ·So we had asked that they had

32· · to:

Page 7082·1· · · · · · · · · · · "Educate and train all [the]

·2· · · · · · · · · ·registered staff on safe storage

·3· · · · · · · · · ·of controlled substances in

·4· · · · · · · · · ·double locked [...] areas or in

·5· · · · · · · · · ·a separate [...] area[s] within

·6· · · · · · · · · ·the locked medication cart.

·7· · · · · · · · · · · [And to] Educate and train

·8· · · · · · · · · ·all registered staff that drugs

·9· · · · · · · · · ·must retain in the[ir] original

10· · · · · · · · · ·labelled container or

11· · · · · · · · · ·packag[ing] provided by the

12· · · · · · · · · ·pharmacy service provider or the

13· · · · · · · · · ·Government of Ontario until

14· · · · · · · · · ·administered to a resident or

15· · · · · · · · · ·destroyed.

16· · · · · · · · · · · Educate all registered staff

17· · · · · · · · · ·regarding the polic[ies] and

18· · · · · · · · · ·procedures for unused or wasted

19· · · · · · · · · ·medication for storage; and

20· · · · · · · · · ·implement the procedure[s] on

21· · · · · · · · · ·administering medications from

22· · · · · · · · · ·properly labelled vials,

23· · · · · · · · · ·packages, strip pouches, and

24· · · · · · · · · ·blister packs dispensed from the

25· · · · · · · · · ·home's pharmacy service

26· · · · · · · · · ·provider.

27· · · · · · · · · · · Develop a procedure to ensure

28· · · · · · · · · ·expired medications are removed

29· · · · · · · · · ·from the medication carts.

30· · · · · · · · · ·Evaluate the implementation of

31· · · · · · · · · ·the procedure to ensure it is

32· · · · · · · · · ·followed by all registered

Page 7083·1· · · · · · · · · ·staff.

·2· · · · · · · · · · · Educate and train all staff

·3· · · · · · · · · ·to ensure that only staff that

·4· · · · · · · · · ·are authorized to administer

·5· · · · · · · · · ·medications fulfill that

·6· · · · · · · · · ·function.

·7· · · · · · · · · · · Educate and train all

·8· · · · · · · · · ·registered staff regarding the

·9· · · · · · · · · ·polic[ies] and procedure for

10· · · · · · · · · ·maintaining a drug record."

11· · · · · · · · · ·Q. Okay, and if we could keep

12· · scrolling.

13· · · · · · · · · ·A. "Implement a system for

14· · · · · · · · · ·establishing accurate and

15· · · · · · · · · ·up-to-date drug records that

16· · · · · · · · · ·include the following

17· · · · · · · · · ·information for every drug that

18· · · · · · · · · ·is ordered and received in the

19· · · · · · · · · ·home:

20· · · · · · · · · ·documentation for every drug

21· · · · · · · · · ·that is ordered and received in

22· · · · · · · · · ·the home;

23· · · · · · · · · ·the signature of the person

24· · · · · · · · · ·placing the order;

25· · · · · · · · · ·the name, strength and [quality]

26· · · · · · · · · ·of the drug;

27· · · · · · · · · ·the name of the place from which

28· · · · · · · · · ·the drug is ordered;

29· · · · · · · · · ·the name of the resident for

30· · · · · · · · · ·whom the drug is prescribed,

31· · · · · · · · · ·where applicable;

32· · · · · · · · · ·the prescription number, where

Page 7084·1· · · · · · · · · ·applicable;

·2· · · · · · · · · ·the date the drug is received in

·3· · · · · · · · · ·the home; and

·4· · · · · · · · · ·the signature of the person

·5· · · · · · · · · ·acknowledging receipt of the

·6· · · · · · · · · ·drug on behalf of the home.

·7· · · · · · · · · · · Maintain and keep a drug

·8· · · · · · · · · ·record for every drug that is

·9· · · · · · · · · ·ordered and received in the home

10· · · · · · · · · ·within the [...] [last] two

11· · · · · · · · · ·years.

12· · · · · · · · · · · Educate and train all

13· · · · · · · · · ·registered staff on the

14· · · · · · · · · ·procedure in the home for the

15· · · · · · · · · ·recording of the daily count

16· · · · · · · · · ·sheets for controlled

17· · · · · · · · · ·substances.

18· · · · · · · · · · · Conduct monthly audits of the

19· · · · · · · · · ·daily count sheets for

20· · · · · · · · · ·controlled substances.· Evaluate

21· · · · · · · · · ·the information gathered through

22· · · · · · · · · ·the monthly audits to determine

23· · · · · · · · · ·if there are any discrepancies

24· · · · · · · · · ·and take immediate action if any

25· · · · · · · · · ·discrepancies are discovered.

26· · · · · · · · · ·Document the actions taken.

27· · · · · · · · · · · Educate and train all staff

28· · · · · · · · · ·on the licensee's policy and the

29· · · · · · · · · ·legislative requirements for

30· · · · · · · · · ·drug destruction of a controlled

31· · · · · · · · · ·substance.· This education will

32· · · · · · · · · ·include training for all

Page 7085·1· · · · · · · · · ·registered staff with respect to

·2· · · · · · · · · ·the licensee's drug destruction

·3· · · · · · · · · ·and disposal policy and how to

·4· · · · · · · · · ·complete the documentation

·5· · · · · · · · · ·record [...]"

·6· · · · · · · · · ·Sorry, I just lost my place.

·7· · · · · · · · · ·Q. It is a long paragraph.

·8· · · · · · · · · ·A. It is a long paragraph.

·9· · · · · · · · · ·Q. I think it is "[...] to

10· · ensure the following information [...]"

11· · · · · · · · · ·That is a lot, and I don't know

12· · if you need to read the entire thing, but all

13· · of paragraph 10.

14· · · · · · · · · ·If we keep going, a lot of

15· · this - and confirm for me - a lot of this

16· · essentially was education and training about

17· · the regulations that they were required to

18· · comply with; correct?

19· · · · · · · · · ·A. Yes, that's correct.

20· · · · · · · · · ·Q. Because we have talked about

21· · a lot of these regulations over the last few

22· · days, but these, the education and the training

23· · and the development of policies and a lot of

24· · the orders were with respect to those different

25· · medication-related regulations.· We had talked

26· · about the fact that those spanned a big chunk

27· · of the regulations, and I think is it from

28· · 114 --

29· · · · · · · · · ·A. 114 to --

30· · · · · · · · · ·Q. -- through 137?

31· · · · · · · · · ·A. Yes.

32· · · · · · · · · ·Q. And these hit many of those;

Page 7086·1· · is that right?

·2· · · · · · · · · ·A. That's correct.

·3· · · · · · · · · ·Q. Okay, and most of these are

·4· · speaking to the other findings, the evidence

·5· · that is supporting your findings of

·6· · non-compliance that ultimately go into the

·7· · section 114 order; is that correct?

·8· · · · · · · · · ·A. They all go underneath the

·9· · umbrella of 114.

10· · · · · · · · · ·Q. Okay.· So let's go to page 4,

11· · and just so that we understand how we approach

12· · this, so we know the order is in relation to

13· · 114, and we see here, we see here what it looks

14· · like is the -- is this essentially your grounds

15· · for the order?

16· · · · · · · · · ·A. These are the grounds to the

17· · order.

18· · · · · · · · · ·Q. Okay.· And if I'm right, it

19· · looks like there are about ten separate

20· · findings or ten separate grounds to support

21· · this order, but they all are essentially

22· · findings of non-compliance with different

23· · aspects of the regulation; is that right?

24· · · · · · · · · ·A. Yes.

25· · · · · · · · · ·Q. Okay.· So the first one we

26· · have is section 114(3)(a) which is the

27· · requirement that is specifically about having

28· · written policies and procedures?

29· · · · · · · · · ·A. And that they are

30· · implemented.

31· · · · · · · · · ·Q. Okay, and what you were

32· · telling us is what you found is that there were

Page 7087·1· · sort of competing policies in the home at that

·2· · time?

·3· · · · · · · · · ·A. There was.

·4· · · · · · · · · ·Q. Okay.· And the next one is

·5· · number 2 and is about purchasing and handling

·6· · of drugs in the home; is that right?

·7· · · · · · · · · ·A. That's correct.

·8· · · · · · · · · ·Q. And that is failing to comply

·9· · with section 122(1)?

10· · · · · · · · · ·A. Yes.

11· · · · · · · · · ·Q. And then the next one, number

12· · 3, that is section 126, so that is about the

13· · packaging of the drugs and so that is what you

14· · were talking about when you were finding

15· · medications in the home like the insulin that

16· · was unlabelled?

17· · · · · · · · · ·A. This is in regards to the

18· · medication that comes in the little medication

19· · packages.

20· · · · · · · · · ·Q. Okay.

21· · · · · · · · · ·A. So the medication had been

22· · removed and were not in the original packaging.

23· · · · · · · · · ·Q. Okay, so similar to what

24· · Rhonda was talking about yesterday?

25· · · · · · · · · ·A. The little square packages,

26· · yeah.

27· · · · · · · · · ·Q. Okay, okay.

28· · · · · · · · · ·All right, and then number 4,

29· · that is section 129(1)(b), so that is a finding

30· · that there was a failure to ensure the

31· · controlled substances were not stored in

32· · double-locked carts?

Page 7088·1· · · · · · · · · ·A. Actually, it is to ensure

·2· · that they are stored in the double-locked

·3· · carts.

·4· · · · · · · · · ·Q. Sorry.

·5· · · · · · · · · ·A. Yeah, that is okay.· The

·6· · Hydromorphone in regards to our observation

·7· · that it was not stored in the double-locked

·8· · carts.

·9· · · · · · · · · ·Q. Okay.· And then that brings

10· · us to 130(3), so that is the monthly audit of

11· · the daily count sheets that you told us you

12· · found had not happened?

13· · · · · · · · · ·A. The daily -- the audits had

14· · not occurred.

15· · · · · · · · · ·Q. Okay, so that is another

16· · regulation with a failure to comply.

17· · · · · · · · · ·Then we have section 131(1), so

18· · that is about the administration.· That is

19· · essentially medication errors, right?

20· · · · · · · · · ·A. That is the administration of

21· · medication not being given as prescribed.

22· · · · · · · · · ·Q. Okay.· And then 131(3) is the

23· · next one, 7, so there that someone is

24· · administering a drug to a resident in the home

25· · but that person is not one of the people who is

26· · entitled to do so; correct?

27· · · · · · · · · ·A. Correct.

28· · · · · · · · · ·Q. Okay, so what had you found

29· · in relation to that?

30· · · · · · · · · ·A. This was in regards to a

31· · medication that was on the eMAR and it is

32· · called Ensure, and the home had had the Ensure

Page 7089·1· · listed as a medication.

·2· · · · · · · · · ·Q. Okay.

·3· · · · · · · · · ·A. And the medication was being

·4· · poured by the Registered Practical Nurse but

·5· · given to a Personal Support Work to provide to

·6· · the resident.

·7· · · · · · · · · ·Q. Okay, what kind of medication

·8· · is Ensure?

·9· · · · · · · · · ·A. Ensure is more of a

10· · supplement base that is ordered by the

11· · dietitian on most occasions, ordered by the

12· · dietitian or the physician.

13· · · · · · · · · ·Q. So when you say "a

14· · supplement", like a vitamin?

15· · · · · · · · · ·A. A supplement like a vitamin,

16· · like a chocolate Resource.

17· · · · · · · · · ·Q. Okay.

18· · · · · · · · · ·A. It is a nutrition, that if

19· · the resident is eating poorly, they could be

20· · given an Ensure as a meal replacement if they

21· · are not hungry.

22· · · · · · · · · ·Q. Okay, and when that is --

23· · that is known as a medication, so that is

24· · something that --

25· · · · · · · · · ·A. At Meadow Park London it was

26· · a medication.

27· · · · · · · · · ·Q. Okay.· All right, so then we

28· · also have that number 8 is a failure to comply

29· · with section 133, so that is in relation to the

30· · drug records and the signatures and

31· · documentation that is required?

32· · · · · · · · · ·A. Yes.

Page 7090·1· · · · · · · · · ·Q. And so can you explain what

·2· · was the evidence that you had found in relation

·3· · to that?

·4· · · · · · · · · ·A. So with the medication that

·5· · was supposed to be received in the home, as I

·6· · was explaining, if a resident has a medication

·7· · that is not on an auto-renewal, which would be

·8· · every seven days the pharmacy would provide the

·9· · strip packaging, so if a resident had a PRN

10· · medication or a medication that was given as

11· · required or as needed and the home was getting

12· · low on the supply, so usually if there is seven

13· · tablets left, the home will re-order that

14· · medication so that they don't run out.· Often

15· · times you'll see this with a controlled

16· · substance that might be given as a PRN pain

17· · medication.

18· · · · · · · · · ·The home then faxes this sheet

19· · over to the pharmacy.· The pharmacy reviews the

20· · sheet and then sends the medication over to the

21· · home.

22· · · · · · · · · ·The registered staff need to

23· · sign in that medication, and in these instances

24· · the medications were not being signed in.

25· · · · · · · · · ·Q. Okay.· So let's scroll down

26· · to the next page, so this is here we have

27· · failing to comply with section 8(1)(b), so that

28· · is of the Long-Term Care Homes Act, not the

29· · regulation, and that has to do with ensuring

30· · that you have all the policies, procedures,

31· · strategies or systems in place as required by

32· · the Act and that those are complied with?

Page 7091·1· · · · · · · · · ·A. That's correct.

·2· · · · · · · · · ·Q. So was this also in relation

·3· · to concerns about the medication policy in the

·4· · home?

·5· · · · · · · · · ·A. This was.

·6· · · · · · · · · ·Q. Okay.· And then finally

·7· · number 10, so this is also a failure to comply

·8· · with a different section, section 134(b), so

·9· · this is:

10· · · · · · · · · ·"[...] failing to ensure that

11· · · · · · · · · ·appropriate actions were taken

12· · · · · · · · · ·in response to any medication

13· · · · · · · · · ·incident involving a resident

14· · · · · · · · · ·and any adverse drug reaction

15· · · · · · · · · ·[...]"

16· · · · · · · · · ·So can you explain what that

17· · finding was in relation to?

18· · · · · · · · · ·A. That was in relation to

19· · Progress Notes in a resident's chart

20· · specifically related to Elizabeth Wettlaufer,

21· · that the resident was receiving a psychotropic

22· · medication who there was a medication incident

23· · or an adverse drug reaction and it was a

24· · psychotropic medication without having an

25· · appropriate assessment completed.

26· · · · · · · · · ·Q. Okay, so the one thing that I

27· · also -- we know this is a lengthy order report.

28· · I want to flip ahead to the specific findings

29· · in relation to section 131, so if we can go to

30· · page 14, please.· So you have anticipated some

31· · of my questions and already told us a little

32· · bit about the -- I think if you keep scrolling

Page 7092·1· · down a little bit, some of -- so we'll start at

·2· · number 6 here:

·3· · · · · · · · · ·"[...] failed to ensure no drug

·4· · · · · · · · · ·was administered [...]"

·5· · · · · · · · · ·So you talked a bit about what

·6· · you had found in relation to the Hydromorphone

·7· · and how it was being stored on the medication

·8· · carts when you found it.

·9· · · · · · · · · ·Can you tell us -- tell us a bit

10· · more -- I had understood there was also an

11· · incident involving Hydromorphone where there

12· · was essentially a borrowing of the medication

13· · from one resident to another; is that correct?

14· · · · · · · · · ·A. I recall that.· I would need

15· · to review my notes to be specific.

16· · · · · · · · · ·Q. Why don't you -- you don't

17· · have to read it out for us, but if you want to

18· · read that, it is also in your -- it is at tab

19· · "B", and it will be on page 14.· If you read

20· · page 14 and then on to the top of page 15 and

21· · tell us what you remember about that.

22· · · · · · · · · ·A. [Witness reviews document.]

23· · · · · · · · · ·This was in regards to the home

24· · had run out of the medication prescribed to one

25· · resident and they did borrow from another

26· · resident.

27· · · · · · · · · ·Q. Okay, and so that is not

28· · permitted under the Act or under the

29· · regulations?

30· · · · · · · · · ·A. The medication should be

31· · ordered and prescribed for that resident and

32· · that specific resident.

Page 7093·1· · · · · · · · · ·Q. Okay.· So did you notice

·2· · while you were in the home, did you notice any

·3· · other medication incidents or medication errors

·4· · of this type?

·5· · · · · · · · · ·A. I don't recall.

·6· · · · · · · · · ·Q. Okay.· And did you review the

·7· · home's records of medication incidents?

·8· · · · · · · · · ·A. Yes, we did.

·9· · · · · · · · · ·Q. Okay.· So we know there was

10· · also a second issue in relation to section 131,

11· · and we had just talked about that, where it was

12· · a PSW who was giving a medication.

13· · · · · · · · · ·So it looks like there were at

14· · least a couple of problems in relation to

15· · section 131, and we know that at Caressant Care

16· · they get an order issued specifically with

17· · respect to 131, but here it is rolled into the

18· · overall finding with respect to section 114.

19· · · · · · · · · ·So can you tell us why that

20· · happened at Meadow Park when Caressant Care had

21· · an order specific to 131?

22· · · · · · · · · ·A. I cannot speak directly for

23· · Caressant Care, as I was not the Inspector at

24· · that home, but for Meadow Park London there

25· · were -- we issued everything under the 131

26· · umbrella so that it would be easier to

27· · understand for the home, but that it was an

28· · order and that the home would have to comply

29· · with all of those sections where there was

30· · non-compliance found under section 114 rather

31· · than issuing -- and at that point, we had not

32· · reviewed the judgment matrix, but had those

Page 7094·1· · occurred, they could have end up with several

·2· · orders related to the Medication Management

·3· · Program.

·4· · · · · · · · · ·Q. Okay.· All right, so I want

·5· · to move on to the other findings of

·6· · non-compliance from this inspection, so that is

·7· · in your Inspection Report, so that is at tab

·8· · "C" of the affidavit and it is doc ID number

·9· · 40987.· If we can just scroll down again, so we

10· · see the date of this report, we see February

11· · 6th and August 15, 2017.

12· · · · · · · · · ·So you said you were in the home

13· · until March, but this report comes out in

14· · August.· Can you explain that?

15· · · · · · · · · ·A. Yes.· We, due to the criminal

16· · investigation that was occurring in the home,

17· · we were directed at that time by Karen Simpson

18· · not to submit the licensee report, and again,

19· · for media reasons as well as not to interfere

20· · with the inspection at that time, because I

21· · don't believe that she had -- charges were laid

22· · until after that date of August 15th.

23· · · · · · · · · ·Q. Okay.· All right, so the

24· · final report comes out, so they are aware of

25· · the Compliance Order, but does the home know

26· · about the other issues of non-compliance at

27· · that time?

28· · · · · · · · · ·A. No, they do not.

29· · · · · · · · · ·Q. Okay, so let's flip to page 3

30· · of this document.· So at the top here it shows

31· · the summary of the non-compliances that were

32· · issued?

Page 7095·1· · · · · · · · · ·A. Uhm-hmm.

·2· · · · · · · · · ·Q. And so it says eight Written

·3· · Notifications, seven VPCs, one CO, and Rhonda

·4· · was asked this morning that that means

·5· · essentially there are eight findings of

·6· · non-compliance; correct?

·7· · · · · · · · · ·A. That's correct.

·8· · · · · · · · · ·Q. And then some of them are

·9· · accompanied by the Voluntary Plan of

10· · Correction?· Seven are accompanied by a

11· · Voluntary Plan of Correction?

12· · · · · · · · · ·A. So, yeah, to unpack it, there

13· · would be seven VPCs with seven Written

14· · Notifications, one Compliance Order with one

15· · notification, one Written Notification.

16· · · · · · · · · ·Q. Okay.· All right, so then

17· · let's flip ahead to the first finding of

18· · non-compliance which is -- well, it is actually

19· · at the bottom of this page, so if we can just

20· · scroll down to the bottom, so it says here

21· · failed to comply with section 19 of the Act, so

22· · that is the duty to protect?

23· · · · · · · · · ·A. Correct.

24· · · · · · · · · ·Q. And if we can scroll to the

25· · next page.

26· · · · · · · · · ·So, Natalie, this finding was

27· · issued in relation to the treatment of a

28· · resident in the home in relation to his

29· · catheter care; is that correct?

30· · · · · · · · · ·A. There was catheter care and

31· · other care concerns around pain management.

32· · · · · · · · · ·Q. Okay, so there were those two

Page 7096·1· · concerns?· There was a lack of a pain

·2· · assessment --

·3· · · · · · · · · ·A. Correct.

·4· · · · · · · · · ·Q. -- on this particular

·5· · resident.

·6· · · · · · · · · ·So I noticed that this review,

·7· · because we know your findings in this report

·8· · include findings of non-compliance in relation

·9· · to the concurrent inspections as well as the

10· · Elizabeth Wettlaufer inspection.

11· · · · · · · · · ·These particular -- the dates in

12· · this particular report go back to 2014.· So was

13· · this something that you had found when you were

14· · looking into the Elizabeth Wettlaufer issues?

15· · · · · · · · · ·A. We were looking at the direct

16· · care that Elizabeth Wettlaufer had provided to

17· · residents in the home at that time that she

18· · worked from April until October of 2016.

19· · · · · · · · · ·Q. Okay.· And so was she the

20· · only nurse involved in caring for this

21· · individual?

22· · · · · · · · · ·A. No, she was not.

23· · · · · · · · · ·Q. Okay.· So this seems, when we

24· · read through it, and I won't have you read

25· · through everything here, but this seemed pretty

26· · troubling in terms of there seems to be a

27· · fairly significant period of time during which

28· · this particular resident is not getting the

29· · care that one would expect in a home; is that

30· · fair to say?

31· · · · · · · · · ·A. Yes.

32· · · · · · · · · ·Q. Okay, and so the details

Page 7097·1· · about this span the next few pages.

·2· · · · · · · · · ·I want to go ahead and I want to

·3· · flip down to page 5, if we could, and if we

·4· · could scroll down to sort of the middle of the

·5· · page, we see here as of July 20:

·6· · · · · · · · · ·"[...] at 2223 the resident was

·7· · · · · · · · · ·screaming and stated that they

·8· · · · · · · · · ·could not sleep."

·9· · · · · · · · · ·Is that typical in a long-term

10· · care home?

11· · · · · · · · · ·A. If the resident is in

12· · distress, it would not be typical.

13· · · · · · · · · ·Q. And what type --

14· · · · · · · · · ·A. And --

15· · · · · · · · · ·Q. Sorry, you continue.

16· · · · · · · · · ·A. When you review that Progress

17· · Note, you would expect that the nurse would

18· · have assessed further as to why the resident

19· · was screaming and could not sleep.· If it was

20· · related to a behaviour, the behaviour should

21· · have been identified in the resident's Plan of

22· · Care.· And that is the only documentation.

23· · They did not provide from that documentation

24· · any type of intervention.

25· · · · · · · · · ·Q. Okay.· And when we continue

26· · down, if we can go down through to the next

27· · page, and we'll see July 30 there is ongoing

28· · issues and there is no pain assessment

29· · initiated, no further monitoring or action

30· · initiated, and we actually see that this

31· · resident on July 30th passes away?

32· · · · · · · · · ·A. That's correct.

Page 7098·1· · · · · · · · · ·Q. So can we go down to the

·2· · bottom here on page 6, so it says -- sorry, on

·3· · page 6.· I have to see where in my notes I was

·4· · looking for this.

·5· · · · · · · · · ·You say in your report, and I am

·6· · trying to find it here -- yeah, towards the

·7· · bottom:

·8· · · · · · · · · ·"The licensee failed to ensure

·9· · · · · · · · · ·[the] resident was not neglected

10· · · · · · · · · ·by staff and failed to ensure

11· · · · · · · · · ·they were provided with the

12· · · · · · · · · ·treatment, care, services or

13· · · · · · · · · ·assistance required for the

14· · · · · · · · · ·health or well-being.· This

15· · · · · · · · · ·includes a pattern of inaction

16· · · · · · · · · ·that jeopardized the health and

17· · · · · · · · · ·well-being of [this] resident."

18· · · · · · · · · ·You then say:

19· · · · · · · · · ·"The severity of this

20· · · · · · · · · ·non-compliance was actual harm

21· · · · · · · · · ·and the scope was isolated."

22· · · · · · · · · ·And you say:

23· · · · · · · · · ·"The home does not have a

24· · · · · · · · · ·history of non-compliance in

25· · · · · · · · · ·this subsection of the

26· · · · · · · · · ·legislation."

27· · · · · · · · · ·And then, ultimately, this is

28· · accompanied by a VPC; is that correct?

29· · · · · · · · · ·A. We did guide that the fact

30· · that this occurred in 2014 and that it was

31· · related to the Elizabeth Wettlaufer inspection,

32· · that we varianced the report to a VPC, and that

Page 7099·1· · had there been any concurrent concerns related

·2· · to the critical incidents we were completing in

·3· · the home, this would be supportive evidence to

·4· · those findings of non-compliance.

·5· · · · · · · · · ·Q. Okay, so when you say you

·6· · varied it, so let's actually pull up, it is at

·7· · tab D of your affidavit, and it is document ID

·8· · 41001.

·9· · · · · · · · · ·So the judgment matrix in fact

10· · would have had as the default action, if we

11· · look down here, and let's look at the -- if we

12· · can see and focus in on section 19(1), the duty

13· · to protect, the judgment matrix default action

14· · here would have been a Compliance Order;

15· · correct?

16· · · · · · · · · ·A. Yes, that's correct.

17· · · · · · · · · ·Q. Okay.· So what you were

18· · saying is you chose to vary it to the VPC, and

19· · explain again, you said it was because it was

20· · part of the Elizabeth Wettlaufer inspection?

21· · · · · · · · · ·A. We were guided that the fact

22· · that these incidents occurred in 2014 and it

23· · was related to the Elizabeth Wettlaufer

24· · inspection.

25· · · · · · · · · ·We had critical incidents and

26· · complaints with this in the home, and had there

27· · been a finding of non-compliance, we would have

28· · used those grounds to support those other

29· · findings of non-compliance from 2014.

30· · · · · · · · · ·Q. I am not sure I understand

31· · the latter part of what you are saying.

32· · · · · · · · · ·A. Okay.

Page 7100·1· · · · · · · · · ·Q. If you had found other

·2· · findings of non-compliance, you would use this

·3· · to support that?

·4· · · · · · · · · ·A. It would support the grounds

·5· · within that order.

·6· · · · · · · · · ·So we issued a Voluntary Plan of

·7· · Correction in 2014.· In 2016 we are completing

·8· · concurrent inspections.· Had we had issues

·9· · related to those critical incidents that would

10· · have been in the section of duty to protect,

11· · that would have been an issue we would have

12· · ordered that as an order and we would have used

13· · this history, because the home has no history

14· · at this point until this inspection in 2014.

15· · · · · · · · · ·Q. Okay.· But this was a case

16· · where you had learned that a man had spent

17· · pretty much the last ten years of his life in

18· · this home in what sounds like significant pain,

19· · and the home takes no steps to do a pain

20· · assessment.

21· · · · · · · · · ·There was clearly actual harm to

22· · this resident from the neglect of the staff.

23· · Isn't that exactly the type of situation where

24· · you as an Inspector should be issuing a

25· · Compliance Order?

26· · · · · · · · · ·A. We issued the severity as

27· · actual harm, so it was a Level 3 when we

28· · completed the judgment matrix, and it was --

29· · · · · · · · · ·Q. And the judgment matrix told

30· · you to issue a Compliance Order?

31· · · · · · · · · ·A. And we varianced the report

32· · related to the history of the home --

Page 7101·1· · · · · · · · · ·Q. So you --

·2· · · · · · · · · ·A. -- as there was no history.

·3· · · · · · · · · ·Q. So, sorry, we can't talk over

·4· · each other.

·5· · · · · · · · · ·So you varied it because there

·6· · was no history of non-compliance --

·7· · · · · · · · · ·A. Non-compliance.

·8· · · · · · · · · ·Q. -- with that section?

·9· · · · · · · · · ·A. At that time.

10· · · · · · · · · ·Q. Okay.· Was there a previous

11· · history in this home in relation to failing to

12· · conduct pain assessments?

13· · · · · · · · · ·A. I would need to review the

14· · compliance history to answer that question.

15· · · · · · · · · ·Q. All right, so let's move on

16· · to the next finding of non-compliance.· So that

17· · is on page 7, and this is section 24.· And I

18· · think we are all becoming very familiar with

19· · section 24 in this room, so this is the failure

20· · to report.

21· · · · · · · · · ·Sorry, if we can go back, I just

22· · realized that I have got -- I have -- so we are

23· · going to go back to document ID 40984 -- oh,

24· · sorry, no, not 40984.

25· · · · · · · · · ·40987 and that is the Inspection

26· · Report, I apologize.

27· · · · · · · · · ·So this finding of

28· · non-compliance in relation to not reporting

29· · under section 24, that specifically had to do

30· · with issues that you uncovered as part of the

31· · Elizabeth Wettlaufer inspection; correct?

32· · · · · · · · · ·A. Correct.

Page 7102·1· · · · · · · · · ·Q. Okay.· So the issue here was

·2· · not reporting to the Director as required.· Can

·3· · you tell us, there was -- in your review of the

·4· · Progress Notes of Elizabeth Wettlaufer, I

·5· · believe that there were three different

·6· · incidents that you reference here that should

·7· · have been reported.· Can you tell us about

·8· · those?

·9· · · · · · · · · ·A. The first incident was in

10· · regards to a visitor that had been in the home

11· · who, according to Elizabeth Wettlaufer's

12· · documentation, showed that the visitor had

13· · pushed another resident.· Elizabeth -- EW's

14· · documentation also showed that she had notified

15· · the management of the home.

16· · · · · · · · · ·The second issue was in regards

17· · to a resident sexually inappropriately touching

18· · another resident.· Through interviews with the

19· · Administrator and Director of Care and the

20· · co-DOC who were working in the home at that

21· · time, the DOC felt that she might have been

22· · aware of one incident that had occurred related

23· · to sexually inappropriate touching, but she had

24· · not reported.· She had thought she reported.

25· · We reviewed our Critical Incident System, and

26· · there was no report submitted from the home in

27· · regards to that incident.

28· · · · · · · · · ·There was also no report sent

29· · from the home in regards to the resident who

30· · had been pushed by a family visitor.

31· · · · · · · · · ·Q. Okay.

32· · · · · · · · · ·A. The third incident was

Page 7103·1· · documentation related to Arpad Horvath that had

·2· · been completed by Elizabeth Wettlaufer.

·3· · · · · · · · · ·Q. I am going to have you pause.

·4· · · · · · · · · ·A. Yes.

·5· · · · · · · · · ·Q. And let's go to page 8, which

·6· · is where this evidence is.· So if we can scroll

·7· · down a little bit, I think it talks about this.

·8· · · · · · · · · ·So the middle paragraph starting

·9· · "The Administrator [...]", so is that what you

10· · are talking about in terms of the evidence?

11· · · · · · · · · ·A. That's correct.

12· · · · · · · · · ·Q. Okay, so tell us about that.

13· · · · · · · · · ·A. So the interviews with the

14· · Administrator, the Director of Care and the

15· · co-DOC, and again, this is in regards to the

16· · 2014 incidents that had occurred, we

17· · observed -- or sorry, the documentation from

18· · Elizabeth Wettlaufer showed us that Arpad

19· · Horvath had been tied tightly by his jogging

20· · pants string to his bed rail.

21· · · · · · · · · ·She also said that she had

22· · assessed his skin and there was no redness, and

23· · that she had reported this incident to

24· · management.

25· · · · · · · · · ·All three of those people, the

26· · Administrator, the co-DOC and the Director of

27· · Care at that time were not aware of the

28· · incident during the interviews.

29· · · · · · · · · ·Q. Okay.· And so you issue the

30· · finding of non-compliance in relation to

31· · section 24.· Explain that.

32· · · · · · · · · ·A. The home has an obligation --

Page 7104·1· · or a person has an obligation to immediately

·2· · report any allegations of abuse or suspicion of

·3· · abuse.

·4· · · · · · · · · ·In this position, Elizabeth

·5· · Wettlaufer had been the manager in the home.

·6· · She was the evening nurse.· She had the

·7· · training and the education, and we reviewed

·8· · that in her HR file, for zero tolerance abuse,

·9· · resident rights and reporting requirements.

10· · · · · · · · · ·We reviewed -- we did weigh

11· · heavily on this documentation for the finding

12· · of non-compliance.

13· · · · · · · · · ·Q. Okay.· And didn't you in fact

14· · also learn during your inspection that the

15· · home's policy in relation to abuse was that a

16· · report had to go to management as opposed to a

17· · report going to the Director; is that correct?

18· · · · · · · · · ·A. The home was using the older

19· · version, so the Unusual Occurrence Reporting.

20· · · · · · · · · ·Q. Okay.

21· · · · · · · · · ·A. I would have to review the

22· · abuse policy to confirm that.

23· · · · · · · · · ·Q. Okay.· So let's go to page 9,

24· · so here we see:

25· · · · · · · · · ·"The severity of this

26· · · · · · · · · ·non-compliance was minimal harm

27· · · · · · · · · ·and the scope was widespread."

28· · · · · · · · · ·It says:

29· · · · · · · · · ·"The home does have a history of

30· · · · · · · · · ·non-compliance in this

31· · · · · · · · · ·subsection of the legislation,

32· · · · · · · · · ·it was issued as a Written

Page 7105·1· · · · · · · · · ·Notification on February 13,

·2· · · · · · · · · ·2015, during a complaint

·3· · · · · · · · · ·inspection."

·4· · · · · · · · · ·And in fact, this is issued with

·5· · a Voluntary Plan of Correction as well.

·6· · · · · · · · · ·But the default action from your

·7· · judgment matrix would have had you issue a

·8· · Compliance Order; correct?· And so why no

·9· · Compliance Order here?

10· · · · · · · · · ·A. Again, we were guided by the

11· · EW inspection and that these incidents had

12· · occurred in 2014.· We weren't seeing those same

13· · issues when we were in the home in 2016 in

14· · reviewing the critical incidents.

15· · · · · · · · · ·Q. So we have heard a lot over

16· · the last couple of days about the importance of

17· · reporting on the part of homes and that you as

18· · Inspectors can't really go in and do your job

19· · unless you hear from the homes about the

20· · problems in the homes; isn't that right?

21· · · · · · · · · ·A. Correct.

22· · · · · · · · · ·Q. Yes, and we have also heard I

23· · believe Karen had said that this is now flagged

24· · as a high risk issue, that non-reporting is a

25· · high risk issue; correct?

26· · · · · · · · · ·A. Yes.

27· · · · · · · · · ·Q. And can you tell us if the

28· · home, for example, had received the report in

29· · relation to Arpad Horvath being tied to the bed

30· · rail -- or sorry, if the Ministry had received

31· · a report about Arpad Horvath being tied to his

32· · bed rail, is that the type of issue that would

Page 7106·1· · likely result in an inspection?

·2· · · · · · · · · ·A. Yes, it would.

·3· · · · · · · · · ·Q. And so how do you say that

·4· · there is minimal harm associated with a failure

·5· · to report in these circumstances?

·6· · · · · · · · · ·A. We issued potential for harm,

·7· · which is a Level 2.

·8· · · · · · · · · ·Q. Okay.

·9· · · · · · · · · ·A. We reviewed -- we did weigh

10· · on the Progress Notes.· We could not speak with

11· · Elizabeth Wettlaufer, which we would normally

12· · do, so that was unusual for us.· We couldn't

13· · really confirm any of the evidence or who she

14· · had reported to.

15· · · · · · · · · ·In her Progress Notes, she did

16· · assess Arpad Horvath and said that he had no

17· · redness in his skin.

18· · · · · · · · · ·Q. But even without speaking to

19· · Elizabeth Wettlaufer, you know the Ministry

20· · didn't get a report; correct?

21· · · · · · · · · ·A. Correct.

22· · · · · · · · · ·Q. So you know her obligation

23· · when she saw that would have been to report to

24· · the Ministry; correct?

25· · · · · · · · · ·A. Correct.

26· · · · · · · · · ·Q. Okay.· Let's move on to the

27· · next finding of non-compliance.· That would be

28· · on page 9.· So this is Written Notification

29· · number 3.· So this here is in relation to pain

30· · management; correct?

31· · · · · · · · · ·A. Correct.

32· · · · · · · · · ·Q. So this is not the same

Page 7107·1· · individual we discussed with respect to the

·2· · section 19 finding where there was a duty to

·3· · protect, but this is someone else who it looks

·4· · like this is actually based on the current

·5· · inspection from 2016 and this was someone and

·6· · this is another case where the home in 2016 was

·7· · failing to do a pain assessment on a resident;

·8· · correct?

·9· · · · · · · · · ·A. Correct.

10· · · · · · · · · ·Q. And if we could scroll down

11· · to -- well, keep going, please.· Thank you.

12· · Keep going to where we are talking about the

13· · severity of the harm, so the next page.

14· · · · · · · · · ·So here it says:

15· · · · · · · · · ·"The severity of non-compliance

16· · · · · · · · · ·was minimal harm or potential

17· · · · · · · · · ·for actual harm, and the scope

18· · · · · · · · · ·was isolated."

19· · · · · · · · · ·You note that the home has a

20· · history of non-compliance in this subsection of

21· · the legislation, and it had a Voluntary Plan of

22· · Correction issued on February 9th, 2016;

23· · correct?

24· · · · · · · · · ·A. Correct.

25· · · · · · · · · ·Q. Okay.· And then if we can

26· · scroll down a little bit, so we know that a VPC

27· · is issued in relation to this.

28· · · · · · · · · ·So as I understand it, the

29· · default action and the judgment matrix was a

30· · VPC; is that right?

31· · · · · · · · · ·A. That's correct.

32· · · · · · · · · ·Q. And was that in part because

Page 7108·1· · it was listed as a minimal harm?

·2· · · · · · · · · ·A. It was actually a potential

·3· · for harm.

·4· · · · · · · · · ·Q. Okay.

·5· · · · · · · · · ·A. For that resident, where we

·6· · talk about you go where the inspection takes

·7· · you, so in this incident it was in regards to

·8· · the Hydromorphone; it was associated to this

·9· · resident.· So then we did look into pain

10· · assessments to ensure that she had been

11· · receiving her Hydromorphone as prescribed and

12· · that her pain management was effective.

13· · · · · · · · · ·Q. Okay, so when I read about

14· · this 2016 failure to conduct the pain

15· · assessment and when I read about that having

16· · also read the details from 2014 where it is

17· · issued under section 19 that there is a problem

18· · with pain assessment there, when I read both of

19· · those together, I struggle to understand why

20· · there is no Compliance Order issued in relation

21· · to pain assessment for this home who has a

22· · history of non-compliance in this area.· Could

23· · you explain that to me?

24· · · · · · · · · ·A. I am not sure I'm

25· · understanding your question that --

26· · · · · · · · · ·Q. So we know the section 19

27· · finding, the first finding that we dealt with.

28· · There was a problem with pain assessment raised

29· · in that?

30· · · · · · · · · ·A. Right, but again, that was

31· · more focussed on neglect.· They were neglecting

32· · to even provide the intervention, not the pain

Page 7109·1· · assessment themselves.· So this resident was

·2· · not receiving pain medication on a regular

·3· · basis.

·4· · · · · · · · · ·Q. But you also -- your findings

·5· · in support of the section 19 specifically

·6· · talked about no pain assessment being

·7· · initiated?

·8· · · · · · · · · ·A. Right.

·9· · · · · · · · · ·Q. So it certainly could have

10· · been issued under this same provision under

11· · section 52 for pain management, couldn't it?

12· · · · · · · · · ·A. That is not how I seen it

13· · during the inspection.· To me, the home had

14· · neglected to care for that resident and meet

15· · the resident's needs.

16· · · · · · · · · ·Q. Okay, but there was a pain

17· · issue?

18· · · · · · · · · ·A. Yes.

19· · · · · · · · · ·Q. And that was a pain issue

20· · from 2014?

21· · · · · · · · · ·A. Uhm-hmm.

22· · · · · · · · · ·Q. And you explained one of the

23· · reasons that you chose not to issue a

24· · Compliance Order there was that it was from

25· · 2014 and there was no history of

26· · non-compliance, but there was a pain issue.

27· · · · · · · · · ·And here we have a pain issue

28· · with a history of non-compliance where -- that

29· · goes along a similar line --

30· · · · · · · · · ·MS. CORRENTE:· Sorry to

31· · · · · · · · · ·interrupt, but I'm going to have

32· · · · · · · · · ·to object at this point.

Page 7110·1· · · · · · · · · · · I think the witness has given

·2· · · · · · · · · ·her evidence, and what I am

·3· · · · · · · · · ·hearing is essentially a

·4· · · · · · · · · ·cross-examination by Commission

·5· · · · · · · · · ·Counsel of her own witness in

·6· · · · · · · · · ·terms of suggesting why

·7· · · · · · · · · ·something should have been done

·8· · · · · · · · · ·a certain way and not another.

·9· · · · · · · · · · · I think the witness has

10· · · · · · · · · ·provided her evidence and we

11· · · · · · · · · ·should leave it at that.

12· · · · · · · · · ·MS. STEPHENS:· In my submission,

13· · · · · · · · · ·I am allowed to ask these

14· · · · · · · · · ·questions.· I am entitled to

15· · · · · · · · · ·cross-examine if I want to.

16· · · · · · · · · · · But I am trying to understand

17· · · · · · · · · ·and make sense from an

18· · · · · · · · · ·Inspector's perspective about

19· · · · · · · · · ·the decisions in terms of

20· · · · · · · · · ·varying the default actions from

21· · · · · · · · · ·the judgment matrix.

22· · · · · · · · · · · I can move on, because we

23· · · · · · · · · ·have other findings to deal

24· · · · · · · · · ·with --

25· · · · · · · · · ·THE COMMISSIONER:· I actually

26· · · · · · · · · ·rule that the question is in

27· · · · · · · · · ·order.· It seems to me to be

28· · · · · · · · · ·highly relevant.· If the answer

29· · · · · · · · · ·is the same, it was her

30· · · · · · · · · ·judgment, it is fine, but I

31· · · · · · · · · ·would like to hear the answer to

32· · · · · · · · · ·the question.

Page 7111·1· · · · · · · · · ·BY MS. STEPHENS:

·2· · · · · · · · · ·Q. Do you want me to --

·3· · · · · · · · · ·A. Sorry, can you repeat the

·4· · question?· Yes.

·5· · · · · · · · · ·Q. Sure, I'll try and remember

·6· · exactly what I said.

·7· · · · · · · · · ·So when I see the section 19

·8· · finding and we talked about the fact that the

·9· · judgment matrix there, the default action would

10· · have been a Compliance Order, and you had

11· · indicated that you had decided to vary it to a

12· · Voluntary Plan of Correction because in that

13· · particular circumstance you were dealing with

14· · information from 2014?

15· · · · · · · · · ·A. Uhm-hmm.

16· · · · · · · · · ·Q. And there was no compliance

17· · history?

18· · · · · · · · · ·A. Correct.

19· · · · · · · · · ·Q. Okay.· But one of the big

20· · issues there had to do with neglecting someone

21· · who was in pain; correct?

22· · · · · · · · · ·A. Correct.

23· · · · · · · · · ·Q. And there was no pain

24· · assessment initiated?

25· · · · · · · · · ·A. Right.

26· · · · · · · · · ·Q. And so here we have a finding

27· · of non-compliance that is current day?

28· · · · · · · · · ·A. Uhm-hmm.

29· · · · · · · · · ·Q. That is from 2016, that is

30· · dealing with pain management and the failure to

31· · initiate a pain assessment; correct?

32· · · · · · · · · ·A. Correct, but the difference

Page 7112·1· · is this is there was a potential for harm.· The

·2· · other one there was actual harm to the

·3· · resident.

·4· · · · · · · · · ·And with this incident with the

·5· · resident not receiving a pain assessment, she

·6· · was still receiving pain medication to

·7· · alleviate the pain symptoms, so there was still

·8· · a potential of harm.

·9· · · · · · · · · ·In the other one for under

10· · section 19 for duty, there had been several

11· · areas of care concerns, not just the pain

12· · assessment, that identified that the resident

13· · wasn't receiving the care that they required at

14· · that time.

15· · · · · · · · · ·Q. So you didn't have concerns,

16· · though, about the ongoing compliance history

17· · problems in relation to pain assessment, even

18· · though I understand with respect to this

19· · particular resident you had decided there was

20· · minimal harm or potential for harm?

21· · · · · · · · · ·A. Can you say that again?

22· · · · · · · · · ·Q. So you didn't have concern

23· · about the ongoing problem in that home in

24· · relation to pain assessment --

25· · · · · · · · · ·A. I did have concern, because

26· · we issued the severity as a potential for harm.

27· · · · · · · · · ·Q. Okay, but ultimately, you

28· · could have varied that; correct?· You have an

29· · option in varying -- in departing from the

30· · default action in the judgment matrix.· You can

31· · vary it up or vary it down.· You had the option

32· · in this case to vary it up, knowing there was

Page 7113·1· · an ongoing compliance history going back to

·2· · 2014?

·3· · · · · · · · · ·A. If pain is a key risk

·4· · indicator, then you could only go up.· You

·5· · wouldn't go down.· And at this time, I cannot

·6· · confirm if pain is a key risk indicator.

·7· · · · · · · · · ·We also have a policy that

·8· · governs us when we are applying the judgment

·9· · matrix, and there are certain criteria that we

10· · need to follow when we are issuing the judgment

11· · matrix.

12· · · · · · · · · ·Q. But you can vary it up?

13· · · · · · · · · ·A. You can vary it up.

14· · · · · · · · · ·Q. Okay, all right.

15· · · · · · · · · ·A. If it is --

16· · · · · · · · · ·Q. Okay, sorry, continue.

17· · · · · · · · · ·A. If it is a key risk

18· · indicator.

19· · · · · · · · · ·Q. You can only vary it up if it

20· · is a key risk indicator?

21· · · · · · · · · ·A. So if you have -- and we have

22· · had changes to this policy, so I am not a

23· · hundred percent sure, so at that time, if

24· · reporting to the Director had not been a key

25· · risk indicator, you could go up or down.

26· · · · · · · · · ·If it is a key risk indicator,

27· · you would only go up.· You wouldn't go down.

28· · · · · · · · · ·Q. Okay.

29· · · · · · · · · ·A. So if -- so for -- and I am

30· · trying to give you an example of one that would

31· · be a key risk indicator.· So if we had a key

32· · risk indicator related to falls, you wouldn't

Page 7114·1· · go down in your judgment matrix.· You could

·2· · stay the same or go up.

·3· · · · · · · · · ·But again, it is based on the

·4· · history in the home, and we do have a policy in

·5· · place that we follow and that Inspectors can

·6· · variance the judgment matrix.

·7· · · · · · · · · ·Q. Which I understand, but I

·8· · just want to confirm this.· We don't think it

·9· · is a key risk indicator.· You could have the

10· · option of varying it up or varying it down?

11· · · · · · · · · ·A. Right, yes.

12· · · · · · · · · ·Q. Yes, okay.· Okay, so let's

13· · move on.· Let's move to page 12, and this is --

14· · so here is a finding of non-compliance in

15· · relation to dealing with complaints, and if we

16· · move to the next page, the next page is just

17· · the legislation.

18· · · · · · · · · ·So if we move to page 14, so

19· · here, as I understand it, this was a finding

20· · because there was a failure to ensure that all

21· · complaints were documented and responded to

22· · within 10 business days.

23· · · · · · · · · ·And as I understand it, there

24· · were a couple of issues.· There was one

25· · particular complaint where there was no

26· · response, response to that individual, but I

27· · also understand that you found that the home

28· · had no record of verbal or written complaints

29· · from 2014 and 2015; is that correct?

30· · · · · · · · · ·A. That's correct.

31· · · · · · · · · ·Q. Okay.

32· · · · · · · · · ·A. Written complaints.

Page 7115·1· · · · · · · · · ·Q. Pardon me?

·2· · · · · · · · · ·A. Just the written complaints.

·3· · · · · · · · · ·Q. Just the written complaints,

·4· · okay.

·5· · · · · · · · · ·And let's go to page 16, and if

·6· · we go to the middle of the page here, so here

·7· · we have:

·8· · · · · · · · · ·"The severity of this

·9· · · · · · · · · ·non-compliance was minimum risk,

10· · · · · · · · · ·and the scope was widespread.

11· · · · · · · · · ·The home does have a history of

12· · · · · · · · · ·non-compliance in this

13· · · · · · · · · ·subsection of the legislation,

14· · · · · · · · · ·it was issued as a Voluntary

15· · · · · · · · · ·Plan of Correction on July 5,

16· · · · · · · · · ·2016 [...]"

17· · · · · · · · · ·And so ultimately, the action

18· · with this is a Voluntary Plan of Correction.

19· · · · · · · · · ·Now, this was another one where

20· · the default action in the judgment matrix would

21· · have been to issue a Compliance Order, but it

22· · was changed, again varied to the VPC.· Can you

23· · explain that to us?

24· · · · · · · · · ·A. Yes.· As you'll notice in

25· · there, the Voluntary Plan of Correction on July

26· · 5th, 2016, there was an issue of non-compliance

27· · related to complaints.

28· · · · · · · · · ·We were in the home reviewing

29· · complaints at that time, and we did not have

30· · the same issues that we had experienced --

31· · non-compliance that we had seen in the 2014

32· · complaints.

Page 7116·1· · · · · · · · · ·Q. Okay, so let's move ahead

·2· · to -- well, actually, we'll scroll down to the

·3· · bottom where we have our next finding of

·4· · non-compliance.

·5· · · · · · · · · ·So this here is section 116.

·6· · This was failing to comply with the annual

·7· · evaluation.

·8· · · · · · · · · ·And if we move to the next page,

·9· · as I understand it -- well, why don't you tell

10· · us, what were the findings to support this

11· · particular finding of non-compliance?

12· · · · · · · · · ·A. "The Licensee failed to

13· · · · · · · · · ·ensure that the annual

14· · · · · · · · · ·evaluation of the medication

15· · · · · · · · · ·management system [...] [and] a

16· · · · · · · · · ·review of the quarterly

17· · · · · · · · · ·evaluations from the previous

18· · · · · · · · · ·year[s] [...] was done by using

19· · · · · · · · · ·an assessment instrument

20· · · · · · · · · ·designed specifically for this

21· · · · · · · · · ·purpose, and identify[ing]

22· · · · · · · · · ·changes to improve the system in

23· · · · · · · · · ·accordance with evidence-based

24· · · · · · · · · ·practices and, if there are

25· · · · · · · · · ·none, in accordance with

26· · · · · · · · · ·prevailing practices."

27· · · · · · · · · ·Q. Okay, and this also -- I

28· · believe one of -- we had talked earlier about

29· · how you had a concern that the staff in the

30· · home didn't understand the policies and

31· · procedures in relation to medication

32· · management.· You also referred to that in

Page 7117·1· · support of this particular finding; is that

·2· · correct?

·3· · · · · · · · · ·A. That's correct.

·4· · · · · · · · · ·Q. Okay, so if we scroll down to

·5· · where -- I'm sorry, I'm going to have -- to the

·6· · page where we talk about the severity of the

·7· · finding.· If you can keep going, there we go,

·8· · back to the top there.

·9· · · · · · · · · ·So we have:

10· · · · · · · · · ·"The severity of this

11· · · · · · · · · ·non-compliance was minimal harm

12· · · · · · · · · ·and the scope was widespread."

13· · · · · · · · · ·And it says:

14· · · · · · · · · ·"The home does not have a

15· · · · · · · · · ·history of non-compliance in

16· · · · · · · · · ·this subsection of the

17· · · · · · · · · ·legislation."

18· · · · · · · · · ·I also understand that this,

19· · again, the judgment matrix had suggested the

20· · default action would be a Compliance Order?

21· · · · · · · · · ·A. That's correct.

22· · · · · · · · · ·Q. But it was varied again to a

23· · Voluntary Plan of Correction.· Explain that to

24· · us.

25· · · · · · · · · ·A. We had reviewed the

26· · Medication IP and had issued section 114 during

27· · the inspection, and then as well as all the

28· · subsections within the Medication IP.

29· · · · · · · · · ·Although we did feel that there

30· · was a potential for harm for not having this

31· · annual evaluation completed, there had been no

32· · history, so at that time we varianced the

Page 7118·1· · report to a Voluntary Plan of Correction.

·2· · · · · · · · · ·Q. Okay, so then let's go to

·3· · page 21, which should be -- this was, if you

·4· · scroll down, this is the finding of

·5· · non-compliance in relation to section 134 of

·6· · the regulation.

·7· · · · · · · · · ·And we had -- we talked about

·8· · this briefly earlier when we were talking about

·9· · the order that is issued in February, but this

10· · particular finding of non-compliance has to do

11· · with Elizabeth Wettlaufer's administration of

12· · psychotropic medication to a resident; is that

13· · correct?

14· · · · · · · · · ·A. That's correct.

15· · · · · · · · · ·Q. And that went back to May

16· · 2014?

17· · · · · · · · · ·A. Yes.

18· · · · · · · · · ·Q. And that resident, as I

19· · understood it reading your report, ends up

20· · being transferred to hospital; is that right?

21· · · · · · · · · ·A. That's right.

22· · · · · · · · · ·Q. Okay.· Was there ever a

23· · Critical Incident Report filed by Meadow Park

24· · in relation to that transfer to hospital?

25· · · · · · · · · ·A. No, there was not, and during

26· · interviews with the DOC, the Administrator and

27· · the co-DOC that were in the home at that time,

28· · they were not aware of this incident.

29· · · · · · · · · ·Q. So they weren't aware that

30· · they had a resident who was transferred to

31· · hospital?

32· · · · · · · · · ·A. They were not aware that

Page 7119·1· · there was any care concerns related to this

·2· · resident.

·3· · · · · · · · · ·Q. Does that surprise you that a

·4· · home is unaware when one of their residents is

·5· · transferred to hospital?

·6· · · · · · · · · ·A. I wouldn't say the word

·7· · "surprised".· Homes, throughout this sector,

·8· · have a way of communication.· Some homes in

·9· · long-term care will have group huddles; they'll

10· · have a morning huddle where they would review

11· · Progress Notes; they would have a discretion

12· · over care that is occurring in the home.

13· · · · · · · · · ·As to whether or not Meadow Park

14· · was having those meetings I am not sure, but

15· · usually during those meetings someone is

16· · reviewing these Progress Notes.

17· · · · · · · · · ·Q. And so how does it actually

18· · happen in a long-term care home if a resident

19· · is having an adverse reaction to a medication,

20· · someone has to call and request that someone be

21· · transferred to hospital?

22· · · · · · · · · ·A. The nurse would contact the

23· · physician or the Medical Director at that time

24· · for orders to transfer the resident to the

25· · hospital.

26· · · · · · · · · ·Q. And then ultimately the nurse

27· · should be charting that?

28· · · · · · · · · ·A. The nurse would chart that

29· · the resident -- in this situation, the resident

30· · had been drowsy and was I recall not being

31· · aroused very quickly, so she had concerns with

32· · her assessment, and the resident was

Page 7120·1· · transferred to emerg.

·2· · · · · · · · · ·Q. So this is a case where

·3· · ultimately, if we scroll down to the severity,

·4· · here we have:

·5· · · · · · · · · ·"The severity of this

·6· · · · · · · · · ·non-compliance was minimal harm

·7· · · · · · · · · ·and the scope was isolated."

·8· · · · · · · · · ·It says:

·9· · · · · · · · · ·"The home does not have a

10· · · · · · · · · ·history of non-compliance in

11· · · · · · · · · ·this subsection [...]"

12· · · · · · · · · ·So a VPC was issued in relation

13· · to this?

14· · · · · · · · · ·A. Yes, that's correct.

15· · · · · · · · · ·Q. And this -- was the VPC the

16· · default action in the judgment matrix?

17· · · · · · · · · ·A. I would need to look at the

18· · judgment matrix.

19· · · · · · · · · ·Q. Okay, we could pull that up.

20· · It is at tab "D" of your materials, and in

21· · fact, why don't you just take a look and let us

22· · know.· If you want, we can pull it up on the

23· · screen, but...

24· · · · · · · · · ·THE REPORTER:· Ms. Stephens, can

25· · · · · · · · · ·we have a moment to switch,

26· · · · · · · · · ·please?

27· · · · · · · · · ·MS. STEPHENS:· Sure.

28· · · · · · · · · ·-- RECESSED AT 5:38 P.M.

29· · · · · · · · · ·-- RESUMED AT 5:38 P.M.

30· · · · · · · · · ·THE WITNESS:· It was a VPC.

31· · · · · · · · · ·BY MS. STEPHENS:

32· · · · · · · · · ·Q. Okay.· So the -- so in terms

Page 7121·1· · of the remaining findings in the report, the

·2· · Section 114, I'm not going to go through that

·3· · because it essentially covers the ground that

·4· · was in the order; is that right?

·5· · · · · · · · · ·A. That's correct.

·6· · · · · · · · · ·Q. Okay.· In fact, that

·7· · particular -- that finding in the report and

·8· · the grounds in relation to that, that's what

·9· · the home already knew about when they end up

10· · getting this report in August?

11· · · · · · · · · ·A. Actually, if you could just

12· · scroll down, we did have, I believe, one WN

13· · that was supportive evidence related to a

14· · concern from 2014 --

15· · · · · · · · · ·Q. Okay.

16· · · · · · · · · ·A. -- of noncompliance.

17· · · · · · · · · ·Q. So where -- do you know where

18· · that is?

19· · · · · · · · · ·A. I believe -- keep going. I

20· · thought it was at the top of the report.

21· · · · · · · · · ·Q. It might have been towards

22· · the top.· We might have passed it because I

23· · felt like I saw 2014.· Can you go back up to --

24· · let's just see.· The beginning of that section.

25· · If you go to page 25, I think that might be

26· · where it is.· But towards the top of 25.

27· · Sorry.

28· · · · · · · · · ·A. So that would be an example

29· · where we had concerns in 2014, but it would

30· · also help support the grounds for an order

31· · issued in 2016.

32· · · · · · · · · ·Q. Okay.· Okay.· So what was

Page 7122·1· · it -- what was it that you found in relation to

·2· · 2014?

·3· · · · · · · · · ·A. It was, again, the

·4· · individual-controlled narcotic sheets were not

·5· · being signed off at shift exchange.

·6· · · · · · · · · ·Q. Okay.· Okay.· Okay.· So

·7· · that's new.· That's added in here because you

·8· · hadn't wanted that in the order report that had

·9· · initially gone out in February; correct?

10· · · · · · · · · ·A. No, that's not correct.· That

11· · was actually added to the report because

12· · probably at that time, we might not have had

13· · that finding written or we hadn't had that

14· · evidence.

15· · · · · · · · · ·Q. Okay.· Thank you.· Thanks for

16· · that clarification.

17· · · · · · · · · ·So we know, Natalie, that in

18· · this report, there were six findings that the

19· · default action would have been compliance

20· · order, and five of these were varied to a VPC.

21· · · · · · · · · ·You say you were guided in

22· · making that decision.· In your Affidavit, you

23· · explain that was because Elizabeth Wettlaufer

24· · was no longer working in the home.· But this

25· · was not a home that had a particularly good

26· · compliance history, was it?

27· · · · · · · · · ·A. It was also related to the

28· · fact that the noncompliance was issued from

29· · 2014.

30· · · · · · · · · ·Q. Okay.· So some of the

31· · findings that we've talked about, though, are

32· · pretty troubling, the failure to do the pain

Page 7123·1· · assessments, the failure to report.· We see

·2· · residents spending their last days in pain.

·3· · · · · · · · · ·Does that seem consistent with a

·4· · focus on residents' rights that Karen told us

·5· · is such an important part of the Long-Term Care

·6· · Homes Act?

·7· · · · · · · · · ·A. As I understand it, resident

·8· · rights is the fundamental principle.· We would

·9· · issue under resident rights, but there was --

10· · we would look to place -- I don't want to say

11· · we wouldn't issue under residents' rights.

12· · · · · · · · · ·I think the easiest way to

13· · explain that, if we had a legislation

14· · requirement -- so under personal health

15· · information, if we felt that the home was not

16· · keeping the residents' personal health

17· · information private, then there was

18· · noncompliance related to that.· There would be

19· · nowhere else to issue those concerns except

20· · under resident rights.

21· · · · · · · · · ·We do find that the fundamental

22· · principle for issuing abuse and neglect is

23· · better founded within the legislation in the

24· · act under Section 23, 24, 20, 21, 19.

25· · · · · · · · · ·Q. Okay.· So let's move on,

26· · Natalie, to the follow-up inspections. I

27· · understand there was a follow-up in the home in

28· · July 2017.· But you weren't a part of that?

29· · · · · · · · · ·A. No, I was not.

30· · · · · · · · · ·Q. Okay.· But in your Affidavit,

31· · you explain that you understand that the COs

32· · were -- sorry, compliance orders were reissued

Page 7124·1· · at that time for Section 114 as well as for

·2· · Section 50, skin and wound assessments?

·3· · · · · · · · · ·A. Yes, that's correct.

·4· · · · · · · · · ·Q. Okay.· So those are my

·5· · questions about the inspection.· I want to ask

·6· · you a few final questions, reflections on the

·7· · inspection system and processes.

·8· · · · · · · · · ·It's now been almost two years

·9· · since we learned of these offences and since

10· · you began those inspections, and we know you

11· · spent a long time in that home, in Meadow Park,

12· · reviewing records, speaking with staff.

13· · · · · · · · · ·Based on what you've learned, do

14· · you think there was anything the Ministry could

15· · have done differently when inspecting at Meadow

16· · Park when reviewing reports that might have

17· · exposed what Elizabeth Wettlaufer was doing

18· · before she chose to confess?

19· · · · · · · · · ·A. No, I do not.

20· · · · · · · · · ·Q. Okay.· Can you explain that?

21· · · · · · · · · ·A. As an inspector in the home

22· · and reviewing the information that was provided

23· · to us in documentation and observations, there

24· · was nothing that suggested that Elizabeth

25· · Wettlaufer was giving lethal doses of insulin

26· · to Arpad Horvath.· Families were not aware.

27· · Coworkers were not aware.

28· · · · · · · · · ·And as we've learned -- I've

29· · learned through this inquiry, that life-saving

30· · medication is available from the pharmacy, that

31· · you can walk up and get insulin.· I was not

32· · aware of that.

Page 7125·1· · · · · · · · · ·She was in a position of power,

·2· · of trust.· And there's nothing at this time

·3· · that says that we could have or the Ministry or

·4· · all the other people who have been involved in

·5· · this to be aware that she was doing what she

·6· · was doing.

·7· · · · · · · · · ·Q. Do you want to just finish

·8· · off by telling us how you've been personally

·9· · impacted by learning about these offences?

10· · · · · · · · · ·A. The last time I tried this, I

11· · cried through the whole thing.· I think that

12· · long-term care for most people is their very

13· · last home.· They're leaving their homes.

14· · They're leaving maybe their partner that

15· · they've had for life.

16· · · · · · · · · ·They're entrusting that the home

17· · is going to provide safe care with respect and

18· · dignity.· And that when you die, you deserve to

19· · die without suffering and without pain.

20· · · · · · · · · ·As a nurse that has worked in --

21· · somewhere in the sector for the last almost 19

22· · years, I have met some of the most amazing

23· · people that have the greatest stories.

24· · · · · · · · · ·I've been very fortunate in my

25· · life to have four grandparents still with me

26· · today who are elderly, and I can't imagine

27· · being a family who has already grieved once to

28· · say goodbye to their loved one, to receive a

29· · call that they have a confession that a nurse

30· · might have murdered their family member and

31· · having to go through that grieving process all

32· · over again.· I can't imagine my mom receiving

Page 7126·1· · or my father receiving a call like that.· My

·2· · heart goes out to those families.

·3· · · · · · · · · ·As for being a nurse, I love

·4· · being a nurse.· I've always loved being a

·5· · nurse.· I feel like Elizabeth Wettlaufer has

·6· · tainted the nursing profession.· There's a lot

·7· · of scrutiny over the profession.

·8· · · · · · · · · ·Nurses are truly caring and

·9· · compassionate people.· They are empathetic.

10· · They are the advocate.· They are the ones who

11· · report themselves.· They're truthful.· They're

12· · calling the physicians.· They're concerned.

13· · · · · · · · · ·That's what nursing is about.

14· · It's providing care to someone and giving them

15· · their dignity and respect.

16· · · · · · · · · ·Reading her Progress Notes at

17· · Meadow Park London over some of the residents

18· · that she cared for and some of the residents

19· · that I knew when I was there, it was extremely

20· · upsetting.· I was sad for those residents

21· · because I do question the type of care she was

22· · providing while she worked in these homes.

23· · · · · · · · · ·It's -- I never ever want to go

24· · through this again, and I don't think anybody

25· · else does.· And if there is any recommendations

26· · that will improve the systems for us and for

27· · everyone else that's living in long-term care,

28· · I hope that they do, and there's -- there's a

29· · change.

30· · · · · · · · · ·But we still have to remember

31· · that everybody is human.· Nurses make mistakes,

32· · but they are good people.

Page 7127·1· · · · · · · · · ·MS. STEPHENS:· Thank you,

·2· · · · · · · · · ·Natalie.· I've got no further

·3· · · · · · · · · ·questions, Commissioner.

·4· · · · · · · · · ·THE COMMISSIONER:· Okay.· Thank

·5· · · · · · · · · ·you.· It's been a long day.· I'm

·6· · · · · · · · · ·not sure how long the Ministry

·7· · · · · · · · · ·would be with it.· I'm just

·8· · · · · · · · · ·wondering if it might be better

·9· · · · · · · · · ·if we break now and --

10· · · · · · · · · ·MS. MINGO:· I may be a little

11· · · · · · · · · ·longer than usual, and I also

12· · · · · · · · · ·feel like the witness may need a

13· · · · · · · · · ·break in any event.

14· · · · · · · · · ·THE COMMISSIONER:· It might also

15· · · · · · · · · ·be a little bit easier to start

16· · · · · · · · · ·tomorrow with the Ministry

17· · · · · · · · · ·questioning and then moving to

18· · · · · · · · · ·the other questioning.

19· · · · · · · · · · · Does that throw your timing

20· · · · · · · · · ·or scheduling?

21· · · · · · · · · ·MS. STEPHENS:· No.· I think we

22· · · · · · · · · ·should still be okay. I

23· · · · · · · · · ·think -- my belief is that

24· · · · · · · · · ·the -- there are fewer people

25· · · · · · · · · ·who will be cross-examining

26· · · · · · · · · ·tomorrow, and I think we should

27· · · · · · · · · ·be able to get through Lisa as

28· · · · · · · · · ·well.· I think a lot of people

29· · · · · · · · · ·are peeling off, so yes.

30· · · · · · · · · ·THE COMMISSIONER:· Okay.· So

31· · · · · · · · · ·then let's call it quits for

32· · · · · · · · · ·today.

Page 7128·1· · · · · · · · · ·THE REGISTRAR:· This Public

·2· · · · · · · · · ·Inquiry is adjourned until

·3· · · · · · · · · ·tomorrow morning at 9:30 a.m.

·4· · · · · · · · · ·-- ADJOURNED AT 5:50 P.M. --

·5

·6

·7

·8

·9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

Page 7129·1· · · · · · · ·REPORTER'S CERTIFICATE

·2

·3· · · · · ·We, DEANA SANTEDICOLA, RPR, CRR, CSR,

·4· · Certified Shorthand Reporter, and CARISSA L.

·5· · STABBLER, RPR, CSR, Certified Shorthand

·6· · Reporter, do certify:

·7· · · · · ·That the foregoing proceedings were

·8· · taken before us at the time and place therein

·9· · set forth;

10· · · · · ·That the testimony of the witness and

11· · all objections made at the time of the

12· · examination were recorded stenographically by

13· · us and were thereafter transcribed;

14· · · · · ·That the foregoing is a true and

15· · correct transcript of our shorthand notes so

16· · taken.

17

18

19· · · Dated this 2nd day of August, 2018.

20

21

22

23

24

25· · · ___________________________________

26· · · NEESON COURT REPORTING INC.

27· · · PER: DEANA SANTEDICOLA, RPR, CRR, CSR

28· · · · ·& CARISSA L. STABBLER, RPR, CSR

29

30

31

32

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com

http://www.neesonsreporting.com