Staff at a Montreal hospital mistreated elderly patients by overusing restraints while failing to provide hygiene care and medical follow-ups, a provincial ombudsman’s report has found.
The report, dated July 2 but released publicly this week, found staff at the Sacré-Cœur-de-Montréal hospital in the Ahuntsic-Cartierville borough often used harmful restraining techniques on patients with little regard for their well-being.
The ombudsman’s report, which came as a result of a complaint filed in October 2024, says staff used both restraining straps and chemical restraints — the use of drugs to sedate patients — improperly.
In Quebec hospitals, restraints are authorized as a last resort, but in Sacré–Cœur’s ward for vulnerable elderly patients, some of whom are awaiting placement in long-term care, staff were quick to use them and failed to properly follow restraint protocols, according to the report.
The ombudsman analyzed the medical records of 18 patients and observed staff working at the hospital on two occasions.
The report details how, in many of those cases, staff immediately resorted to restraints without considering the needs of the patient.
For example, in one case, staff administered sedatives to a patient who was screaming. They couldn’t understand what the patient was saying due to a language barrier but learned later the patient had been in pain.
In another case, it took months for staff to learn that a patient’s aggressive behaviour was caused by hunger. In yet another, staff gave a patient Tylenol only to later realize their agitated behaviour was caused by a knotted catheter.
Sometimes, patients were restrained for days without proper health checks and re-evaluations.
Most of the time, once staff restrained patients, those restraints were left on even though procedure mandates they only be kept on as long as necessary, the report says.
The ombudsman noted cases where patients sat restrained in soiled diapers without food or water for hours.
The report also said staff repeatedly failed to administer proper hygiene and feeding care to the patients, which the ombudsman qualified as mistreatment.
The ombudsman issued 10 recommendations that include regular audits to ensure staff are applying proper procedures as well as spotting cases of mistreatment and intervening when necessary.
A spokesperson for the CIUSSS du Nord-de-l’île-de-Montréal, the health authority that oversees the hospital, called the report “troubling.”
“It is our duty to provide care and services that are high-quality, safe, humane and respectful,” the spokesperson wrote in a statement.
“We are fully committed to working with the ombudsman and are in the process of implementing the recommendations contained in the report.”
The spokesperson said additional measures had already been taken to ensure a higher quality of care, including the daily presence of nursing care experts and managers to support the staff.
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