MOOSE JAW — An Ontario woman who believes her Moose Jaw-based aunt died because of poor health-care treatment says she still wants justice for her relative, even though a report says the woman’s concerns are unfounded.
Natalia da Costa-Cox and her husband, Alan Cox, were in Moose Jaw in 2021 from the end of June to mid-July, visiting Alan’s aunt, Jennie (Jean) Shankoff. Shankoff, 83, had been in the Dr. F.H. Wigmore Regional Hospital since early June after falling at home.
Shankoff — who was diagnosed with breast cancer and early dementia — spent a month in the hospital before she was transferred to Marcie Private Care Home at 1301 Princess Street on June 29. She spent two weeks there before she died on July 10.
Da Costa-Cox contacted the Moose Jaw Express in 2022 to express her concerns about the care her aunt received and to raise awareness of the poor care seniors receive.
She also contacted the Ministry of Health with concerns about Marcie Private Care Home and its owner/director, Miriam Nganzo. After investigating the situation, the ministry said the investigator was unable to substantiate the complaints, which the report also confirmed.
The ministry also told her that it couldn’t intervene because the care home was privately operated. Similarly, the Saskatchewan Ombudsman was unable to offer any support, either.
Da Costa-Cox then contacted the College of Registered Nurses of Saskatchewan (CRNS), which investigated the woman’s complaints.
In a recently released report, the investigators dismissed the allegations and recommended to the college’s discipline committee that no further action be taken since the “facts were not found to support professional misconduct or (professional) incompetence” by Nganzo or her team.
“This was just another slap on the face! I feel so angry!” da Costa-Cox told MooseJawToday.com by email. “There’s no words to describe how I feel!”
Continuing, da Costa-Cox said others had warned her not to be optimistic about the investigation’s outcome since “no one wins.” She pointed out that people often die “in these (care) homes’ hands,” and she believes there’s no accountability, nor do operators admit any wrongdoing.
“It’s outrageous! I will continue to fight for justice … ,” she continued. “I feel sick to my stomach that (the CRNS) didn’t take (the concerns) seriously… . It’s not fair. The Ministry of Health needs to know!”
Da Costa-Cox added that she will make one more attempt to catch the provincial government’s attention and encourage it to act.
Report’s findings
The investigation committee said in its report that it reviewed the Coxes’ four complaints, including that Nganzo:
- Did not seek timely medical guidance or provide adequate pain management for Shankoff
- Did not provide appropriate medication storage or management, nutritional support, wound care management, or attend to Shankoff’s medical needs
- Failed to ensure the personal care home (PCH) was adequately staffed and that employees were trained appropriately and qualified to perform some care
- Failed to ensure standard infection prevention and control measures were followed
Claim No. 1
The Coxes said the care home gave Shankoff only Tylenol for pain, while they insisted that a physician attend and provide stronger medication, the report said.
However, the committee concluded that no evidence existed showing that the PCH had not sought timely medical guidance or failed to adequately address Shankoff’s pain. The only pain the staff saw was when they repositioned Shankoff on her bed since she had developed a lower back wound at the hospital.
The report added that during Shankoff’s 10 days at the PCH, the venue consulted with a physician, a physician visited twice, and the care home arranged the palliative care orders after the woman’s arrival.
Claim No. 2
The Coxes said Shankoff was placed in a dirty and cold basement room with improper hygiene and cleanliness; there were ants on the floor and bugs on the walls; and they never saw anyone clean the room, the report said.
Nganzo told the committee that the basement room was temporary since the family planned to move Shankoff to another care home — that Nganzo owned — once its elevator was fixed. The report noted that no evidence existed showing that Shankoff had been harmed either when EMS transferred her to the basement or when staying there.
The committee did find, however, that putting the woman in the basement — even temporarily — violated the care home’s licensing condition that non-ambulatory residents should not be housed there. So, it deferred to the ministry’s PCH consultant to provide ongoing oversight of the venue’s compliance with conditions.
Nganzo also told the committee that staff cleaned the room daily, gave Shankoff baths every morning and regularly changed the woman’s incontinence products, the report said. While the Coxes said staff cleaned their aunt’s wound with a glove covered in feces, Nganzo denied this and said she would correct any unhygienic practices immediately.
“The committee is not satisfied that this evidence supports an allegation that the member did not provide appropriate care,” the document added.
The Coxes also said staff forgot to feed Shankoff, provided cold food and fed her last; that the woman had a bladder infection that was not addressed; and that da Costa-Cox was left alone with Shankoff when she died.
After investigating, the committee found that a microwave was present to reheat the food if necessary and that Nganzo directed employees to feed Shankoff directly. Furthermore, the woman’s cancer medications affected the colour of her urine, which made it look as if she had an infection.
“The committee acknowledges the trauma that the (Coxes) experienced being alone when (Shankoff died),” the report said.
However, the document noted that Nganzo spent the entire night with the woman and went home to sleep after the Coxes arrived. She texted them at 2 p.m. and again at 2:50 p.m., when she learned Shankoff had died.
Claim No. 3
Nganzo was required to always have one employee present, and did so, while she had extra staff working during Shankoff’s stay and when it was busy, the report said. Furthermore, staff did not need to be RNs to work there, while trained staff could administer medication via injections under the skin.
The committee also found that the care home primarily administered hydromorphone to address Shankoff’s pain, the report added.
Claim No. 4
The Coxes said the care home failed to comply with COVID-19 precautions, while they said they saw staff using feces-covered gloves, the report said.
Nganzo told the committee that patients didn’t need to wear masks since it was their home, while staff followed self-check protocols. She also denied that staff failed to change their gloves.
After investigating, the committee accepted that patients and staff complied with the relevant public health orders. As for the gloves, the committee added that it was unlikely that the allegation could be proven based on the limited evidence provided.
