A Niagara-on-the-Lake long-term care home, where an altercation between two residents has led to a manslaughter charge, has been the subject of two “critical incident” investigations since March.

Chartwell Niagara at 120 Wellington St. was sanctioned by provincial inspectors on Sept. 19 for failing to ensure that two patients were protected from abuse related to separate incidents in 2018 and 2019.

The September order by inspector Kelly Hayes from the Hamilton office of the Ministry of Health and Long-term Care included what the ministry calls two written notifications, one voluntary plan of correction and one compliance order, according to public documents posted on the ministry’s website.

The orders stem from a “critical incident inspection” conducted over six days between Aug. 14 and 21.

The inspection was in response to a “resident to resident altercation that resulted in injury” and a fall that “resulted in a change in a resident’s condition.”

Last week, Niagara Regional Police charged Robert Barry Stroeh, 74, with manslaughter in the death of Verna Traina, 94, after an incident at Chartwell Niagara on Aug. 9. Traina died at Greater Niagara General Hospital on Aug. 20.

Stroeh was released on $500 bail and returned to Chartwell Niagara, where he continues to reside.

It is not known whether the ministry inspection is related to the fatal incident as police, ministry and Chartwell officials would not provide details.

However, an anonymous source who alerted The Lake Report to the existence of the ministry reports claims they are the same incident.

The reports are convoluted and full of health care jargon and awkward terminology. As a result, deciphering exactly what happened is difficult.

The Lake Report is attempting to outline the main details of the reports so readers have an overview of the investigations and the outcomes.

Because all residents are anonymous and only identified by three-digit numbers, it is not known how much overlap, if any, there is among the various reports and incidents.

The September report, which orders Chartwell Niagara to ensure “all residents in the home are protected from physical abuse by resident #001,” gives the home until Nov. 15 to comply.

Chartwell says that has been done. “We have taken all required steps to fully comply with the order,” spokesperson Janine Reed said in a statement to The Lake Report on Tuesday.

The ministry report notes Chartwell Niagara has a “history” of compliance issues. The ministry’s website lists 13 complaint reports between 2010 and February 2019, but only two other critical incident investigations, in 2010 and 2012.

The report by Hayes says, “This order is made up on the application of the factors of severity (3), scope (2), and compliance history (3). This is in respect to the severity of actual harm that the identified residents experienced, the scope of this being a pattern, two of three residents reviewed, incident. The home had a level 3 history as they had previous noncompliance” with the Long-term Care Homes Act, including a written notification in April 2019.

The September investigation notes an incident occurred between residents #001 and #002 on an “identified date” in 2019. Exactly when is not revealed. The report cites Chartwell for not protecting resident #002 from abuse.

The report also refers to a 2018 altercation between resident #003 and #004 (who was injured) and a prior incident between #003 and #008.

Reed said the residents in the 2018 altercation are not the same people involved in the 2019 incident.

As a result of the ministry’s investigation of that altercation, “Resident #003 was discharged from our residence,” she said in response to questions from The Lake Report.

The second ministry critical incident inspection report is dated April 11 and is related to seven days of investigation from March 18 to 27 headed by inspector Aileen Graba.

Concurrent with the April critical incident probe was an inspection related to a resident’s complaint about a particular personal support worker, a plan of care violation and staffing and record-keeping concerns. That investigation was overseen by Graba and inspector Lisa Bos.

The April report cites Chartwell for failing “to ensure that all residents were protected from abuse by anyone.”

The document says a resident suffering from “cognitive loss” and identified only as #001, and another patient, #002, also suffering cognitive loss, were involved in a physical altercation in which #002 was injured. The extent or seriousness of injuries is never outlined in any of the reports.

The April document concludes Chartwell Niagara failed to protect resident #002 from “abuse by anyone” and also did not “ensure that for each resident demonstrating responsive behaviours, strategies were developed and implemented to respond to these behaviours.”

It is unclear from the April report when the incident occurred, only that it happened on an “identified date.”

With different resident numbers and few details, it is unclear whether this incident is the same 2018 altercation mentioned in the September investigative report.

Because officials, citing privacy concerns and patient confidentiality, won’t reveal details of all the incidents, it also is unclear how serious any of the incidents actually were and if the same patients were involved in some instances.

The Lake Report is continuing to follow this story. Contact editor@niagaranow.com.