The records from Alberta Health obtained by The Canadian Press under access to information legislation say there were 39 incidents of abuse of people with intellectual disabilities for the period between July 1, 2010, and May 1, 2012.
The Alberta government initially released some records but they were incomplete. The Canadian Press successfully appealed to the Alberta Office of the Information and Privacy Commissioner, which later ordered that redacted decision reports on abuse investigations be released.
The decision reports chronicle a range of abuses, ranging from shouting at a resident to deaths.
The province defines abuse under its Protection of Persons in Care Act as "an act or omission causing serious bodily harm." The law requires an investigator to show an incident of abuse occurred on a balance of probabilities.
The records say two people died in incidents that related to an omission. One person in a wheelchair died in hospital after he fell down basement stairs and another person died after being scalded by hot water.
There were a total of 21 cases of staff abusing people in their care, the reports say. Those incidents included shouting and hitting.
There were also 18 cases of residents abusing other residents where investigators decided staff could have taken steps to prevent the abuse.
Frank Oberle, the associate minister responsible for persons with disabilities, says he's confident care homes in the province are safe and the number of abuse cases are small.
"I'm not aware that it's a huge problem or a big problem ... my feeling is that it's not widespread," he said in an interview. "We have excellent staff out there and excellent caregivers and where there are abuses we've put mechanisms in to catch them."
However, the reports describe staff shortages and a need for training.
One report says that on Nov. 4, 2010, a person with "profound developmental disabilities" fell down steps leading to a basement after a door was left unlocked at a facility operated by the Parkland Community Living and Supports in Red Deer. The investigator says the man died seven days later in hospital.
The investigator concluded two home workers were aware the basement door was to be locked but didn't check it.
Dan Verstraete, chief operating officer at Parkland Community Living and Supports, says the home will comply with the recommendations of a fatality inquiry into the death when it is complete.
In several incidents, investigators found facilities weren't properly staffed when a person with intellectual disabilities abused a housemate. The records also cite training as a problem.
In a September 2010 incident at Accredited Supportive Living Services in Olds, Alta., a care worker screamed at a resident who had wet themselves.
Linda Maxell, the executive director of the facility, said the staff member involved in that incident is no longer working at the home.
"It's not OK, absolutely not OK. I mean, our job is to take care of people, not expose them to anything that demeans or hurts them," she said.
"We have abuse protocols in place, we do the training with the staff. ... It's like anything. You're going to get some people who don't follow all the rules."
The province's highest profile incident occurred on Oct. 23, 2011, when 35-year-old David Holmes died after being burned on his feet and lower legs when he was bathing at Supported Lifestyles in Calgary. The agency did not return messages seeking comment.
The death attracted media coverage but Holmes's death wasn't the only incident involving serious burns.
On July 31, 2010, an investigation report says a person with a brain injury was burned in a shower while travelling with a caregiver hired by Advocate Community Resources in Calgary.
The report says the person sustained burns to the back, neck, shoulders and arms, and that the person didn't receive medical attention within a reasonable period of time. Four days passed before the first- and second-degree burns were treated by a doctor.
Advocate Community Resources did not return messages seeking comment.
The province has ordered that temperature regulators be installed at facilities that deal with people with developmental disabilities and staff were ordered to follow specific safety procedures.
The largest number of incidents happened at the provincially run Michener Centre in Red Deer, which houses 229 people and is one of a few larger facilities that remain open in Canada.
It had seven cases of residents abusing other residents, with several physical attacks.
Cheryl Chichak of Alberta Human Services says the Michener Centre is a safe facility but it houses people with severe disabilities who have communication and behavioural problems.
"So you do get some altercations between individuals. But the staff are very skilled at handling those situations and they respond right away," she said.
"Michener is a large environment so you're going to see more incidents there than a home with just a couple of people living in it."
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