Raw hot dogs served with undercooked fries.
Cold soup residents beg to have warmed up.
Fish so overcooked it feels like jerky.
These are some of the meals served to residents of a Chartwell long-term care home in the Greater Toronto Area, according to a family member.
“Even before the pandemic, the food was awful,” Sean Chiasson told HuffPost Canada.
Chiasson visited his 97-year-old grandmother at the home every day at lunchtime before the pandemic hit last March.
During those visits, he’d heat up residents’ soup, served at the beginning of every lunch for those who arrive in time for it. He couldn’t get to everyone in the dining room, but said he tried to at least help the residents at his grandmother’s table and those surrounding it.
In the spring, Chiasson’s grandmother was suddenly put on a pureed diet — without consultation or approval from her family, he alleged. Although he eventually got the home to reverse the change, for the days she was on it, she refused to eat the “mush” she was served.
The 97-year-old has lost more than 40 pounds since the start of the pandemic.
“ … As a human being, they should have dignity, and, you know, proper health and nutrition,” Chiasson said.
A spokesperson for Chartwell did not respond by deadline.
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Ontario’s Long-Term Care Home Act states homes must have alternative choices available at meals.
“If the home’s menu cycle does not meet a resident’s nutrition needs, the home must develop an individualized menu for the resident,” it states.
Tanya Blazina, a spokesperson for the Ontario Ministry of Long-Term Care, said the ministry takes compliance with the act seriously, and encourages residents and families to contact the family support and action line if they have concerns.
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Most long-term care residents are at risk of malnutrition and dehydration, which can lead to an increased chance of falls, infections, hospital admissions and overall mortality, according to Dietitians of Canada.
Experts say because of the importance of residents eating nutritious food, more attention needs to be given to their diets. That includes more provincial funding so homes can meet residents’ dietary needs and cook food on site instead of contracting it out.
Families told HuffPost even before the pandemic their loved ones struggled with a lack of culturally appropriate food, were confused over why they were fed pureed food, and wouldn’t eat the food provided to them. They also said at short-staffed homes there aren’t enough workers to help residents eat — before the pandemic was further affecting staffing levels.
Blazina said homes are still required to provide adequate assistance and eating aids or assistive devices to residents eating in their rooms. She added the most recent visitor policy allows for essential caregivers, who can provide extra support to residents eating in their rooms.
Meal time is often the highlight of residents’ days, and an important time for socializing and maintaining independence, a 2015 report from York University researchers states. But during the COVID-19 pandemic — which has so far claimed the lives of more than 3,000 long-term care residents in Ontario — many are served alone in their rooms, without the prolonged assistance from family or staff they may require.
The Canadian Armed Forces, which was deployed to several Ontario long-term care homes in the spring, reported residents were force fed and forced to drink water, which caused “audible choking.”
There were 660 incidents of food and nutrition issues — from missed meals to residents choking and gastroenteritis outbreaks — reported by Ontario long-term care homes between January 2018 and May 2019, according to a 2019 auditor general (AG) report.
That included 27 cases of unexpected resident deaths because of choking and aspiration, and 100 cases of abuse or neglect of a resident by staff related to food that caused harm or risk of harm.
In 2018, six per cent of the ministry’s inspections related to aspects of food or nutrition, per the auditor general report. That number, according to the report, was 13 per cent in 2015, the last time the AG audited the long-term care inspection program. (At the time, the ministry was called the Ministry of Health and Long-Term Care; the two were made separate ministries in 2019.)
Food ‘for the pigs’
“S**t on a plate” is how June Morrison’s father, a resident at Orchard Villa long-term care home in Pickering, Ont., used to describe his pureed meals there.
George William Morrison died during the COVID-19 pandemic. Orchard Villa was Ontario’s hardest-hit home in the first wave.
She recounts one day when she visited and her father’s hamburger looked like “a mound of this brown stuff.”
“And I put a fork into it, took a mouthful, and I go, ‘OK, I now understand why nobody wants to eat this,’” she told HuffPost.
Morrison’s father, who used to live on a farm, would tell her the food on his plate appeared to be “for the pigs.”
Staff at the home, Morrison said, refused to give him non-pureed food, even when she offered to cut it. So he wouldn’t eat.
He also didn’t want to eat the food he found unfamiliar. Having grown up in Scotland, he was introduced to foods like spaghetti and rice later in life. Once his dementia took hold, he didn’t recognize those foods anymore and refused to eat them.
Candace Chartier, Chief Seniors’ Advocate and Strategic Partnerships Officer at Southbridge Care Homes, which operates Orchard Villa, said in a statement personal support workers record nutritional assessments, which are then reviewed by registered nurses, daily.
“In the event where a resident may refuse food or fluids, staff members will re-engage with the resident at a later time,” she said, adding these interactions are documented to identify patterns to discuss with a resident’s designated contact.
“Menus are established in advance, and residents are offered a selection of two options at each meal,” Chartier said. “Any resident with specific dietary needs or requirements are accommodated, in consultation with our dietician and family partners.”
As much as what’s on the plate, the simple social experience of eating in the dining room is also important for residents.
When George first moved to Orchard Villa, he was paired with another resident to eat together. He really enjoyed the man’s company and the two would have conversations together while they ate. But, Morrison said, the home later separated them without giving a reason. When the man died, George was “brokenhearted.”
“They need to pair people up with people that converse with them. Because if you lose that ability to talk to somebody, then you just grow into yourself…. You’ve got no mental stimulation at all,” Morrison said.
Chartier said the home encourages “positive resident-to-resident interactions” but “resident care appointments” may result in changes to a resident’s routine.
‘Huge gap’ in food inspections
Shauna Prouten, a registered dietitian in B.C. who has worked in long-term care, told HuffPost a home should take residents’ preferences — and right to self-determination — into account when planning their meals.
She said downgrading a residents’ diet should only happen on a temporary basis until they can be assessed by an expert, like a speech language pathologist or occupational therapist. There are lots of variations a home could employ before going right to pureed food, Prouten said, such as bite-sized or minced diets.
“I think too often, facilities just have a very limited repertoire, and there’s nothing in between the regular or the cut up [food] and the pureed,” she said.
It’s easy for homes to provide menus that aren’t meeting residents’ needs, if their menus are not being observed or inspected, Prouten added.
She pointed to the 2019 AG report’s finding that in five homes assessed, registered dietitians and nutrition managers said in the last three years they’d never been asked by ministry inspectors for the nutrient analysis of their home’s menu.
The AG report also said the ministry doesn’t require homes to report on food and nutrition performance indicators.
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“And so very rarely do you see audits done, full audits done, on the nutrition services in long-term care,” she said. “That is a huge gap.”
“I think they need to have inspectors go in there at mealtimes, and actually take a look at the nutritional plan for the day that covers the masses, plus look at the records of those that are diabetic or look at the fact that people are refusing food,” she said, adding inspectors need to see if residents can explain why they’re refusing food and if it’s because, as her dad experienced, it doesn’t look right.
Blazina, from the Ministry of Long-Term Care, said inspectors found non-compliance related to food and nutrition in 127 inspections in 2019, and 80 inspections in 2020. The ministry has assigned inspectors to monitor long-term care homes during the pandemic, she said.
“Proactive inspections assess food and nutrition, and concerns related to food and nutrition are also inspected as a result of complaints and as risks are identified during the course of other types of inspections,” she said.
Under the province’s Long-Term Care Act, a registered dietitian is required to complete a nutritional assessment for all residents in the home, and again in the event a residents’ health changes significantly.
Better menu planning needed
There are a number of factors that limit residents’ food intake, including individual eating challenges, the dining room environment and how staff interact with residents in the dining room, Heather Keller, the Schlegel Research Chair in nutrition and aging at the University of Waterloo, told HuffPost.
In her research analyzing long-term care home menus, she’s found a need for across-the-board improvements in several provinces, regardless of whether a home was for-profit or not.
An analysis of menus in four provinces found meals given to residents are lacking in a number of nutrients, including vitamin D and calcium.
The lack of nutritious food for residents points to a need for better menu planning in long-term care, Keller said.
“It’s certainly a money factor, but it’s also a policy factor about how we plan menus and making sure that the people that are in homes have the time and the skill to do that well.”
She found some homes planned their menus for up to 18 months in advance, which she called “inappropriate.” Homes should have a shorter menu cycle of around three weeks, Keller said, to reduce repetition and take advantage of seasonal ingredients. Staff should also review menus at least twice a year to address changes in a home’s population, changes in food supply and cost of food, as well as be using local food.
Keller recommended homes use the Dietary Reference Intakes (DRI) — guidelines based on nutrition, not food groups — to plan menus, instead of Canada’s food guide.
That would cost $12 per resident per day, she said — up from the current ministry funding of $9.54 per each resident’s raw ingredients per day. (While families or residents pay for part or all of their room — this is sometimes subsidized by the government — homes receive ministry funding for personal care, programs, raw food and other accommodations, according to the AG report.)
But it’s also important to consider the cost of supplemental pills or drinks if residents aren’t currently getting the nutrients they need, she said.
“We need to have policy [makers] realize, ‘Hey, to feed people well, it takes money’ — not just food money but also staff money.”
The ministry spokesperson said licensees are responsible for ensuring menus provide adequate nutrients based on both the DRIs established in reports from the United States National Academies, and include a variety of foods in line with Canada’s food guide.
Despite her research showing the need for change, Keller said there are people currently working to improve the food in long-term care.
Dietitians of Canada, along with several other organizations, put out a paper in the summer about menu planning in long-term care. Their report recommends using the DRIs as standards for meal planning and states menus should be “based on in-depth knowledge” of the needs and preferences of residents.
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In March 2020, Pat Armstrong, a sociology professor at York University and long-term care researcher, wrapped up a decade-long examination of food at 27 long-term care homes in six countries.
One of the most important findings, she told HuffPost, was the value of food being cooked on the premises of a home instead of being contracted out, as is the case in some Ontario homes.
She said it’s important for residents to be served by staff who know them and their preferences.
In one home that contracted out food, Armstrong’s team observed a sign that prohibited the contract workers from talking to residents.
Contracting out has several other negatives for residents: food being prepared offsite means they can’t smell the aromas, which can make residents less likely to want to eat. When food is contracted out, courses are often served all on one plate, which research shows can lead to residents eating less. It also makes it more difficult to adhere to cultural or dietary needs if food is being mass-produced offsite by people unfamiliar with residents’ care plans.
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But a trend toward privatization in long-term care as a way of reducing costs has led to homes contracting out food services, Armstrong said.
“We give such a piddly amount for raw food, and in terms of homes … it’s really hard for them to produce good food on site,” she said.
She said she wants to see the province increase its funding for food, and ban contracting out of food services — a move she said would be a “major step forward.”
The ministry spokesperson said it increases its allocations to the raw food funding each year, as well as its contributions to a category of funding called “other accommodations,” which homes can use for raw food if they choose to.
Prouten, the B.C. dietitian, noted food is an important part of residents’ quality of life — from the way it looks, to its flavours and presentations, to it being served in a way that they can chew and swallow as an enjoyable experience.
“You have these people that their island of operation opportunity is shrinking and their island of choice is shrinking, so they have very few opportunities in their life to make choices,” she said. “Food is one of those things where they can choose, and they can choose right up to the last breath, often.”