05/13/2015 03:44 EDT | Updated 05/13/2016 05:59 EDT

Ombudsman investigation finds Saskatchewan long-term care under strain, has gaps

REGINA - The family of a 74-year-old woman whose death raised questions about long-term care in Saskatchewan hopes her case will help protect vulnerable seniors.

Leanna Macfarlane said she was relieved that an ombudsman's investigation confirmed her concerns about the care of her mother-in-law Margaret Warholm.

"The home terribly failed her ... the government failed her, everyone failed her," Macfarlane said. "It doesn't bring her back but we're just happy that it helped other people."

The ombudsman's investigation found nursing homes are under strain and there are gaps in long-term care.

Mary McFadyen's report said there is a culture of distrust between staff and management at the care home where Warholm lived. It also said care aides described a stressful environment.

"Many staff reported that their work schedules result in burn-out and increased sick leave," the report said. "Some stated that when they tried to raise issues, management was either unavailable, or unsupportive and blaming."

The report also said there are no immediate consequences for care homes that fail to meet provincial guidelines.

Health Minister Dustin Duncan said he wants to implement all of McFadyen's 19 recommendations, which range from improving communication with families to publicly reporting on whether facilities are meeting guidelines.

"We know that this isn't isolated to an individual facility or to a region," he said.

Medical records show Margaret Warholm, who lived at the Santa Maria Senior Citizens Home in Regina, reported losing 30 pounds in a year and had compression fractures in her spine.

She also had a large bedsore on her back. Warholm died days after being admitted to hospital in October 2013 following a fall.

McFadyen's report pointed to problems with Warholm's care, including inconsistencies in treating her fragile skin and contradictions in her care plan that were noted in a medical chart.

She said her office has received 89 other complaints about long-term care since she launched her investigation in November.

"Bluntly put, most people who contacted us simply said that all they wanted to know was whether their mother or father was safe, clean and properly fed," she said. "That, in my opinion, is not a lot to ask for."

McFadyen said issues included poor communication, lack of accountability and no clear way for families to complain about the care of loved ones.

John Kelly, executive director at the Santa Maria home, said changes have been made since Warholm's death to improve communication and clarify the process for staff to bring forward complaints.

"We're on a journey from where we are to where we want to be," he said. "We have numerous families that are quite happy with the care that's provided and we're going to continue to go forward with that."

Kelly added understaffing isn't a problem.

The Opposition NDP has been criticizing the quality of seniors care for months. The New Democrats are calling for a seniors advocate, higher staffing levels and minimum-care standards.

"The communication aspect between staff and families, it shouldn't have to be like pulling teeth and banging your head against the wall to get answers about your loved one," said NDP Leader Cam Broten.

"We need to change the culture within the facilities."