Two healthcare workers accused of improperly documenting and failing to provide adequate care to a woman at the Hanna Health Centre in December 2020 have each been ordered to take additional courses and write a Behaviour Improvement Plan in a decision by the College of Registered Nurses of Alberta (CRNA).
It is alleged both healthcare workers, on multiple occasions throughout the patient’s hospital stay between the late evening of Christmas Day 2020 and early morning of Boxing Day 2020, failed to adequately assess the patient and make appropriate documentation.
The patient, 40-year-old Lillian Vanasse, who was of Ojibwe descent, was brought to the Hanna Health Centre emergency room by ambulance in the late evening of December 25, 2020. An initial assessment, which included an echocardiogram (ECG), was performed, and she was later taken to the hospital’s x-ray room by a lab technician for further testing.
While in the x-ray room, one of the healthcare workers, Holly Conners, acknowledged she had entered the x-ray room and found Ms. Vanasse “leaning on a counter” and then shortly afterwards “lying down on the floor” and expressing she was unable to stand; Ms. Conners also acknowledged she had failed to document Ms. Vanasse’s “dramatic change in circumstance” as outlined in Alberta Health Services (AHS) guidelines and standard practices.
Ms. Vanasse was transferred to a smaller patient room as per COVID-19 protocols in place at the time. Any persons entering the room were to don personal protective equipment, which was to be removed upon exiting.
Paper was not permitted within the patient treatment room due to the COVID protocols, and a whiteboard instead was used to record treatment information, which was to be later transcribed into the patient’s chart.
Shortly after being transferred into this room, Ms. Vanasse became unresponsive at approximately 1 a.m., and resuscitation attempts were made in a “collaborative and team effort” between the two healthcare workers and an attending physician until Ms. Vanasse was pronounced deceased at 2:57 a.m. on December 26, 2020.
The tribunal acknowledged the incident took place during the height of the COVID-19 pandemic, resulting in a “high-stress situation” due to ongoing protocols and short staffing at the rural hospital; the tribunal also noted documentation of Ms. Vanasse’s care “needed to be complete.”
It was acknowledged there was over an hour in which Ms. Vanasse’s cardiac rhythm was not documented during resuscitation efforts; these are meant to be checked and documented every two minute CPR cycle, and it was confirmed by the physician on duty that these were checked every two minutes.
The Mail had previously reported in March 2023 the hearings had been closed to the public. At the time the reason for the closure was not made public, however, in the published decision document it was noted the closure was made due to concerns for public safety and security due to the small population of Hanna, and social media posts and comments made by Ms. Vanasse’s widower, who is the complainant, which “expressed animus, threats, and punitive actions'' against the two healthcare workers.
While the tribunal “considered (the complainant’s) valid comment, in one of his postings, that this matter needed to be heard transparently and openly for the benefit of the public,” it also considered the potential risk to the two healthcare workers.
Based on evidence and submissions from legal counsel for the two healthcare workers, the tribunal ordered Ms. Conners to complete a Documentation in Nursing and Nursing Process Self Study course and write a 1,500 word self-improvement plan, both to be completed by December 1 of this year; the other healthcare worker, Marcia Campbell, was also ordered to complete the Documentation in Nursing course along with writing a 1,500 word self-improvement plan by December 1, 2023.
These conditions will be placed on both practice permits and will be removed once complied with.