Margaret Warholm, 74, was a resident at the Santa Maria Senior Citizens Home in Regina when she was admitted to hospital in October 2013 for severe abdominal pain. She died days later of a gastro-vascular disorder.
"We're still grieving — and it's been over a year — because it wasn't fair," Leanna Macfarlane, Warholm's daughter-in-law, said Wednesday.
Medical records show that Warholm reported losing 30 pounds in a year and had compression fractures in her vertebrae. Her family attributes those to a fall Warholm took while aides were moving her at the centre. She also had a large bedsore on her back that Macfarlane believes could have been prevented.
The Opposition raised the case in question period as an argument for minimum care standards in the province.
NDP Leader Cam Broten said afterwards that standards for senior care in Saskatchewan are like a "patchwork quilt."
"Stories of not having the right food, of not getting the type of care, not getting the baths that people need, I hear these all the time," he said.
"This government needs to recognize that these aren't one-off random things. This is a pattern."
Medical records released by Warholm's children show that when she was admitted to hospital she was "quite immobile and in severe pain."
Macfarlane said family members regularly visited Warholm at the seniors home, but they didn't move her because she had spinal stenosis, which is a narrowing of the spine that causes compression. She said they relied on aides at the centre to bathe and move Warholm.
That's why they never actually saw how big the bedsore was.
"We were told she had a bedsore the size of a quarter."
But when Warholm was admitted to hospital for an unrelated issue, nurses were shocked at the size of the sore and the rash across her back, she said.
Warholm's daughter, Nancy Macfarlane, said the discovery was devastating.
"If we would have known, we would have done something for her," she said, crying. "We felt guilty. We put her there to be taken care of and she wasn't taken care of."
Executives from Regina Qu'Appelle Health Region visited the Santa Maria facility on June 4, 2013, and conducted a quality assessment. The report stated that there was "general concern about having enough staff.
"Management advised that they are trying to maximize the use of resources they have, but are still lobbying for more care resources per resident day," the report said.
Broten suggested under-staffing contributed to Warholm's lack of care.
"We feel like we failed her, and not only did we fail her, they failed her," said Leanna Macfarlane.
The Santa Maria centre didn't immediately return calls for comment.
In a letter to Warholm's family dated Nov. 6, the centre's executive director, John Kelly, wrote that "a number of matters related to the care of Mrs. Warholm should have been better managed."
Kelly listed plans for changes that include "enhanced dining for residents" and a better charting system to "allow for better care planning, communication and followup."
He said staff involved in Warholm's care were advised that they did not provide the expected standard of care.
"They have been/will be provided with remedial training," the letter said.
Health Minister Dustin Duncan said seniors care is a priority for the government and there are expectations laid out for facilities.
He would be happy to speak to Warholm's family, he said, although he isn't familiar with the details of what he called a "troubling case."
Duncan said he doesn't think under-staffing is an issue across the board.
"I think specific to areas like Regina and Saskatoon, they would have different issues than some of our smaller rural facilities."