Guy Maisonneuve held back tears the day he dropped his 95-year-old mother, Aline Besner, off at a Gatineau, Que., care home on Feb. 26.
Her room smelled like urine, staff wouldn’t make eye contact and no one would help transfer Besner into bed, he says. That was just within the first few days on the second floor of Villa des Brises.
Located in the private facility managed by Mandala Santé, the floor is partly run by the regional health authority, the Centre intégré de santé et des services sociaux de l’Outaouais (CISSSO).
The floor is designed as a temporary residence for post-acute care and a place for those who may need rehabilitation before returning home or getting transferred to a long-term placement.
“From the moment I stepped into the villa, I was filled with dread, absolute dread,” said Maisonneuve, sitting at his kitchen table, steps away from the room where he hoped his mother would spend her final days, at home.
But after being diagnosed with advanced dementia at the Wakefield hospital, Besner moved into the Villa des Brises transitional unit while waiting for a permanent placement at a long-term care facility.
A bad first impression soon turned into major concern for Besner’s safety when Maisonneuve was told by a neighbouring resident his mom was having falls, didn’t have access to drinking water, wasn’t being bathed regularly and that her emergency call button would either be out of reach or go unanswered for hours.
On April 14, Besner died in a hospital bed, surrounded by her family. Quebec’s coroner’s office is investigating her death.
More families and former residents are coming forward, some claiming abuse and “incompetence” on the transitional floor.
The care home would not comment on specific events. Mandala Santé and the regional health authority both declined repeated requests for an interview.
“Every fibre of our being was screaming, get her out of there. And that’s what she would say: just get me out, take me out of here,” said Maisonneuve’s wife, Shelley Langlois.
“I will regret it for the rest of my life that I didn’t take her out,” added Maisonneuve.
Connecting with other residents, Maisonneuve and Langlois say they realized Besner wasn’t the only one experiencing what they call neglect.
Cries for help
The night of April 11, Besner cried out for help for nearly six hours, says Sharon Nobert, her former neighbour at the facility.
No one answered, she says.
Placed in a room across the hall from Besner while she was recovering from a broken ankle and knee, Nobert says she “didn’t sleep a wink.”
“I was yelling, too, for somebody to come and help her,” said Nobert. “Nobody did.”
The next morning, as Nobert was taken out of her room for breakfast, she saw Besner on a stretcher, leaving with paramedics. That was the last time she saw her.
Langlois and Maisonneuve say Besner lost consciousness at the care home and never woke up when she was taken to the Hull hospital. The family decided to pursue end-of-life care.
Before Besner died, Langlois says she and Maisonneuve were approached by doctors who had made a discovery of “profound bed sores” on Besner’s back.
The bruised open sores lined her back and tailbone. Her family had no idea.
They consented to Besner being photographed by doctors who filed a complaint against the residence — prompting a coroner’s investigation into the circumstances surrounding Besner’s death.
“It was a long, rich, beautiful life. And for the last six weeks of it to have been such a horrifying nightmare, we’re stuck there,” said Langlois.
‘Every single day I found incompetence,’ says former resident
Steve Connolly says he was “destroyed” by Besner’s situation.
Connolly, a former resident who lived down the hall on the transitional floor, would write his daily observations — compiling nearly 40 pages of notes during his seven-week stay.
Since moving back home to Low, Que., he’s been sounding the alarm about the emergency response time on the care home’s transitional floor as well as staff and management issues he witnessed.
“Every single day I found incompetence, indifference, negligence and abuse,” said Connolly.
He has been in contact with the office of Quebec’s complaint commissioner and CBC News has seen his email exchanges. He says he feels unsupported by the commissioner’s office.
Some staff ‘couldn’t care less,’ says family of former resident
The problems in the home are likely systemic, says Steven Burgess.
He’s been trying to understand what happened to his 80-year-old father during his final days in Villa des Brises.
His father had moved to the transitional floor in February after having several falls. During a visit, Burgess says he noticed a handful of staff who seemed like “they couldn’t care less.”
He says he saw some staff using their phones and ignoring alarms.
“Doesn’t that bother you? Doesn’t the noise get annoying?” he recalled asking one staff member.
“And [they] said, ‘No.'”
Burgess says his father died suddenly on April 10, leaving his family with many questions over his rapid decline. He says he received conflicting information from staff on the transitional floor about the events which led to his father’s death.
“It was the suddenness of it, and it’s the lack of answers that I think hurt the most,” said Burgess.
In an attempt to get answers, he also brought his concerns to the complaint commissioner.
‘Bureaucratic labyrinth’
In an emailed statement, the CISSSO confirmed it has 76 beds in Villa des Brises, with 33 beds on the transitional floor.
It says the residence offers personal assistance services while the CISSSO provides professional services — including nurses, occupational therapists, social workers and physiotherapists — for its beds on the floor.
“Users and their loved ones are invited to contact their intervention worker if they have any concerns,” read a statement from the health authority.
“Quality of care and service is a priority for us.”
The CISSSO says it is following a quality improvement plan.
Besner’s family filed a report with the complaint commissioner, but Langlois says they have been waiting months for a response.
She says they’ve been trying to grieve while also navigating a “bureaucratic labyrinth.”
The complaint commissioner told CBC News that all files are confidential. The coroner’s office confirmed its investigation is ongoing.
In an email, a public relations firm responding on behalf of Mandala Santé said every report of neglect or abuse is treated with “meticulous attention.”
“In the event of laxity among our employees, we do not hesitate to take disciplinary action, including dismissal if necessary, despite the labour shortage in the region,” read the email.
It says the home is co-operating with ongoing investigations and that no complaints have been received “recently” — adding that residents have expressed “their sense of security and the friendliness of the staff.”
Connolly says addressing all the concerns brought up from residents who lived on the transitional floor in the spring is bound to take more than a couple months.
During his stay, he says he had to threaten to call 911 at least twice to get staff to respond to emergency call buttons in neighbouring rooms.
He recalls hearing Besner’s faint cries from down the hall early in the evening on April 11. On another occasion he said he responded to an emergency call from a neighbour who had fallen on her back. He says the staff “did nothing.”
More than once, Connolly says his room was not properly cleaned — forcing him to do it himself.
“I wanted to get out of there so fast,” said Connolly, breaking down.
Nobert says the problem lies in training — or the absence of it.
“It’s undisciplined,” she said.
Nobert says she had to call for help one night to use the toilet in her room due to her full leg cast. She says a staff member came in, on a FaceTime “work call” and proceeded to rest the phone on Nobert’s bedside — where she was in full view of the camera.
“I could see him and he could see me in all my glory. So I was not pleased with that at all,” said Nobert. “It’s not the right thing to do.”
Nobert never complained because she said she worried about reprisals.
In an emailed response, the office of Sonia Bélanger, Quebec’s minister responsible for seniors, said she is following the situation closely and is aware of an ongoing coroner’s investigation.
“I can also assure you that there is zero tolerance for any form of abuse or neglect, whether physical or psychological,” read the statement.
But Maisonneuve and Langlois say they’ve received little meaningful response from politicians, the regional health authority’s complaint commissioner or Mandala Santé — which runs four other homes in the province.
The family decided to file a complaint with Quebec’s ombudsman, the Protecteur du citoyen du Québec, citing an “unacceptable delay” in the treatment of their file submitted to the complaint commissioner.
“We really feel like we’re screaming into a void. We have no idea whether there’s anyone on the other end,” said Maisonneuve.
“We don’t want anyone else to have to go through this.”