For 59 years, Fred Rieser never made a decision without his wife, Alma, by his side.

But, when it came time for him to make decisions on his wife’s behalf, with Alma beset by Alzheimer’s and Fred designated to speak for her, he was locked out, he says.

The Ontario Ministry of Health and Long Term Care has found that Millennium Trail Manor care home in Niagara Falls, Ont., failed to involve cognitively impaired resident Alma Rieser’s substitute decision-maker — her husband Fred Rieser — in discussions about her care in the final days of her life.

Alma Rieser, 88, died at Millennium Trail Manor in February 2016.

Fred Rieser, 84, says that in the four days leading up to her death, as Alma suffered the symptoms of pneumonia and was given multiple medications, staff never once spoke to him about his wife.

He wishes he had been able to offer his input.

In a July 14, 2016 report, the Ministry of Health determined that Millennium Trail Manor was in “non-compliance” with the province’s Long Term Care Homes Act, when it “failed to ensure that the resident’s substitute decision-maker was given an opportunity to participate fully in the development and implementation of the resident’s plan of care.”

The Long Term Care Homes Act, which sets out the regulations for Ontario’s care homes, says that every resident has the right to “participate fully” in the development, implementation and revision of their plan of care.

Ontario’s Health Care Consent Act states that a substitute decision-maker is authorized to give or deny consent to treatment on behalf of a patient incapable of doing so themselves.

In an email to the Star, Millennium Trail Manor administrator Lori Turcotte said the home “cannot comment on this issue since it is currently in legal proceedings.”

On Dec. 14, Rieser filed a civil suit against Dr. Hemraj Porwal, Millennium Trail Manor and Conmed Health Care Group, the private company which owns the home.

The suit’s statement of claim, sent to the Star by Rieser’s lawyer Margaret Hoy, says that Porwal was “responsible for the assessment, diagnosis, medical care and treatment” of Alma Rieser at Millennium Trail Manor.

The claim further alleges that, when Alma contracted an infection around Feb. 4, 2016, she was “not referred to hospital, provided with appropriate medication, x-rays, diagnosis (or) medical treatment.”

The statement of claim says that, as a result of “missed diagnoses and treatment,” Alma Rieser developed “severe and permanent complications which caused her death.”

The suit calls for $300,000 to be awarded to Fred Rieser for “general and special damages,” plus legal costs.

The allegations in the statement of claim have not been proven in court.

The Ministry’s July 14 report on Millennium Trail Manor does not include anyone’s names, referring instead to “Resident #001” and “the resident’s Substitute Decision- Maker.”

In correspondence with the Star, Fred Rieser and Hoy identified Resident #001 as Alma Rieser.

Fred Rieser provided the Star with funeral home documents indicating that his wife died at Millennium Trail Manor in February 2016, and a letter from one of the inspectors who investigated Millennium Trail Manor, in which the inspector gives him the Ministry’s report.

In the report, posted to the Ministry’s public reporting website, inspectors lay out the sequence of events leading up to the resident’s death, and its immediate aftermath.

On an unspecified date in 2016, Alma Rieser began showing signs of an infection, was vomiting and had a fever.

Staff gave her medication to treat those symptoms.

As Alma’s health declined, a physician requested that a “specimen” be obtained from her, and said that, once an infection could be confirmed, Alma should be started on another medication.

Staff were unable to obtain the specimen. The following day, the physician started Alma on the infection medication.

She died later that day.

It had been four days since she began showing symptoms of an infection.

Fred Rieser, her substitute decision-maker, had visited Alma in the care home on every one of those days, but was never informed by staff about her care, the report states.

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Inspectors reported that, according to clinical records, Fred “was upset” when informed of the resident’s cause of death.

But the same staff member who documented that Fred was upset, failed to inform the coroner that a deceased resident’s family had voiced concern.

When any long term care home resident dies, the facility’s staff are obligated to fill out an Institutional Patient Death Record to notify the coroner.

That form includes the question, “Has the family or any of the care providers raised concerns about the care provided to the deceased?”

When filling out the record for Alma’s death, the Millennium staffer answered “no,” to that question, the Ministry report said.

The report also stated that Millennium staff failed to properly document Alma’s eating habits.

And, as Alma’s care needs changed, staff failed to revise her “plan of care,” which directs health professionals on a patient’s treatments, the report says.

Jane Meadus, lawyer for the Toronto-based Advocacy Centre for the Elderly, says it is not at all rare for long term care homes in Ontario to exclude substitute decision- makers from discussions of their loved ones’ care.

“This report really highlights a systemic problem in long term care, and this is not in any way specific to this home,” says Meadus.

This is not the first time that Ministry of Health and Long Term Care inspectors have found Millennium to be in non-compliance with the Long Term Care Homes act.

In the five years between January 2012 and January 2017, more than 20 Ministry inspection reports found Millennium Trail Manor to be in non-compliance. Many of those reports cite multiple instances of non-compliance.

Reported incidents include staff failing to review and revise residents’ plans of care, staff failing to document instances when residents displayed inappropriate sexual behaviour or physically and verbally aggressive behaviour and, in at least one case, a staff member physically harming a resident. That staff member was terminated.

The Ministry of Health and Long Term Care says it investigates every complaint it receives about long term care homes.

In the July 14 report, inspectors issued Millennium three written notifications, three voluntary plans of correction and one correction order, in connection with the care of Alma Rieser and a separate non-compliance relating to the pain assessment of another resident.

Any time a care home is found not to have complied with the Long Term Care Homes Act, inspectors issue a written notification of non-compliance. Depending on the severity of the infraction and the home’s history, inspectors may require the home to create a “voluntary plan of correction” to fix its problems, or issue the home a compliance order, mandating that it fix its problems.

If a home is unable or unwilling to make the necessary changes, the ministry may cease the home’s admissions, reduce or withhold funding to the home, or revoke the home’s license.

David Jensen, spokesperson for the Ministry of Health and Long Term Care said the province intends to introduce changes, including stiffer penalties, in early 2017.