Medevacs, re-used syringes and the wrong medication: Inside Naja Isabelle group home
Department of Family Services announced investigations 1 year ago into facility after 3 residents hospitalized, 2 of whom died; Authorities still won’t say what happened
A third-party review of issues at the Naja Isabelle Medical Home in Chesterfield Inlet includes details about the care offered at the facility at the time three residents were hospitalized. Two of those residents died; one in October 2023 and the other in January 2024. Family Services Minister Margaret Nakashuk, whose department handled the contract for care at the home, has not offered any interviews on the matter. (File photo by Jeff Pelletier)
A year after the Department of Family Services announced investigations into “critical incidents” at a group home in Chesterfield Inlet, it’s still not clear what caused the deaths of two residents and the hospitalization of another.
But a third-party review into the quality of care offered at the Naja Isabelle Medical Home provided to the Department of Family Services on Jan. 12, 2024, gives some details of “deficiencies” found at the time in the medical care provided by staff at the home.
The review, prepared by Knowledge Council Inc., lists several problems at the facility but does not specifically refer to the critical incidents announced on Feb. 16, 2024, that spurred the investigation.
Naja Isabelle Medical Home was a residence for children and adults with specialized medical needs, run by Pimakslirvik Corp. since 2004.
A 12-year-old resident of the home died Jan. 6, 2024, and a 19-year-old resident died Oct. 17, 2023, after they were hospitalized, along with a third resident. It’s not clear when the residents were hospitalized.
The Knowledge Council review commenced on Dec. 7, 2023, and reflects information provided to investigators as of 5 p.m. on Dec. 20, 2023.
It included 26 recommendations to improve service at the group home, but the Government of Nunavut declined to renew its contract with Pimakslirvik after it expired March 31, 2024.
The review found, among other things, evidence of “delayed access to medical care and inappropriate medical interventions for respiratory issues when health conditions were escalating.”
“There is evidence that when a resident was in an acute medical crisis, the medical provider failed to follow its own policy to contact the community health centre and transport the resident immediately.”
It also points out that nurses were “prohibited” from taking residents in need of medical care to the health centre without authorization from the director of care, and that these delays resulted in “several” medevacs in 2023.
The review also found concerns with the handling and dispensing of medications.
“Employees were re-using single-use syringes by washing or steaming [them] in the microwave,” it said.
Syringes were pre-filled with medication, but not properly labeled; the narcotics cupboard was unlocked; narcotics counts were being conducted by one nurse when two were required; and there was no internet access at Naja Isabelle, which meant staff could not look up medications.
“We also found a critical incident report which noted that the wrong medication was administered to a child,” the review said.
The most recent incident report investigators found was dated Aug. 31, 2023. Some incident reports were missing information and it appears there were times when they were not filled out at all.
“When we reviewed the medevacs in 2023, we found no evidence of a corresponding incident report in the resident’s chart or corresponding binder,” the review said.
An asphyxiation risk is also highlighted in the report, which notes residents using a feeding tube did not have their heads elevated 35 to 45 degrees.
Staff retention and training appeared to have caused issues as well at the group home. The return rate for nurses was found to be “extremely low,” while the reliability of activity aides was “inconsistent.”
There were also issues with leadership.
“We also learned that it is a common practice for managers to ignore and walk away from nursing staff when they ask questions,” the review said.
“We heard reports of physical and emotional confrontations between Inuit staff and staff from the south.”
As part of the government’s service contract with Pimakslirvik, the Department of Health and Social Services was required to review the facility annually.
But investigators found that in the entire 21-year history of the home, there were only two annual reviews: One in April 2002 and another in November 2011.
Investigators found evidence that a review was initiated in 2021, but could not determine whether it was completed.
It also found no evidence the Department of Family Services had ever conducted an annual review.
Marc Ippiak, CEO of Pimakslirvik Corp., said “I have no comment at all” when reached by Nunatsiaq News.
Nunatsiaq News contacted the Nunavut RCMP on Feb. 11 for an update on the criminal investigation and was told that police “needed time” to determine its status.
Nunatsiaq News also contacted the Department of Family Services for an interview with Minister Margaret Nakashuk or anybody with the department, regarding the report’s findings.
“Family Services respectfully declines to comment or be interviewed on this matter,” said Tina Rose, a spokesperson with the department.
It’s disheartening to read this and see that the children and adults in critical care, who trust the workers to treat them well, are not receiving the care they deserve. Why do individuals choose to become nurses or aides? I was raised to believe that one should pick a career that they are passionate about and that will make a difference, even if it’s just in small ways. Many people want to become nurses or aides because they genuinely want to help others and improve the lives of those they care for…
I’ve also heard that the elder care home in Arviat isn’t the best due to management issues. It is run by the same company that held the contract for Naya Isabelle, although I’m not sure if that contract is still active.
“nurses were “prohibited” from taking residents in need of medical care to the health centre without authorization from the director of care…”
Why would anyone add this kind of friction, almost guaranteed to slow responsiveness, to a context like critical care? The stupidity is infuriating.
Criminal and civil lawsuits should be happening
Absolutely ghastly.
Gross incompetence.
I feel for the southern staff who want to help and have nobody to turn to for help. Must be terrified alot by small town….(everything) and severe isolation.😱🤯
Who’s to bless and who to blame ? Usually there’s several sides to the issues at hand as in most “issued” situation. In Nunavik as well, we see a care not attitude coming from two sides. We must consider the consequences of the impact. First remember the goodness in people from professional side, and likewise in local Inuit and non Inuit living as ordinary citizens in our communities. The Good is always a bit further ahead than the alternative. The bad side includes those from south that are coming as professionals and have no experience or training to deal with common issues and cultural challenges. There’s a big disconnect. We have selfish local people who are self serving and keep Inuit from advancing as a population. They want all without sharing. Two of theses negative energy runs our small communities as well as larger. Maybe I’m not saying anything new, surely not, but think about how the rotten apples appears in any vulnerable barrel.
PJ’s government is a driverless train.
7 more months of pictures
Unfortunately, this starts with the leadership team at Family Services Headquarters. You can’t continue having Directors/ADMs who harass and bully service providers and expect great service. The kickback contracts need to stop as well. Work with service providers in the territory and stop sending children, youth and adults who can clearly get services in the communities. Not every Nunavummiut needs to be sent down South. Also, it’s time that Inuit learn to work with people who are willing to do the work. Working together is the only way that change can happen and take place. Also, stop just being ready to report any little thing because of your old mentality that no one else but Inuit should be helping and taking care of those need.
When people in leadership roles talk about those they serve in a degrading way, there is no hope for those individuals who desperately need the help. As a community, we need to work together in demanding change and aligning ourselves with people who truly care in this community. Change starts with each one of us.
This is a terrible story. And from what I understand it has been going on for a long time. Heads should roll for allowing this to happen for so long.
Gross Negligence, Incompetency to say the least.
Children’s LIVES. LIVES. Actual human lives…Lets’ not forget that.
The GN has played with children’s lives for how long? At what point do we consider this abuse?
Why is the Minister not being held responsible?
Disgusting.