Nearly seven months after Angelina Geraldi’s death, her family is no closer to understanding what happened after she fell out of bed at her long-term care facility just before Christmas last year.
The 97-year-old died at CHSLD LaSalle less than a day later and the coroner opened an investigation into her death — referring the case to the Montreal police.
Since then, Geraldi’s family says they’ve been left in the dark.
“They’re not allowed to tell you who was working. They’re not allowed to tell you what’s going on,” said Geraldi’s granddaughter, Alice Costello.
She says all the CHSLD staff were willing to say was that the orderly, or préposées aux bénéficiaires (PAB), working that night was suspended. They were also told the nurse on duty was working two floors and on a break when the incident occurred, Costello said.
A fall at her daughter’s house is what prompted Geraldi’s move to the LaSalle long-term care home a few years ago. Fracturing her hip and leg, Geraldi needed around-the-clock care and was fully dependent on the care home’s staff to help her get in and out of bed and into her wheelchair, said Costello.
An early riser, Geraldi was usually one of the first residents the staff would get ready in the morning. But when Costello popped in for a quick visit following an exam at school last December, her grandmother was still in bed and she was surrounded by employees.
“The pain was excruciating in her leg,” said Costello. “They were trying to find out what happened.”
She died after a fall at a care home. Her family still doesn’t know what happened
Another resident told Costello he’d heard Geraldi calling for help during the night, but no one responded for hours. He told them he buzzed for an orderly who came to her aid.
Costello said her grandmother was not a small woman, so it would have taken a lot of strength to pick her up off the floor and get her back into her bed.
“She had a bruise on her arm, her legs were bruised and the leg that was already fractured was worse. It was not able to be moved. It couldn’t be touched,” said Costello, who recently graduated from a home care assistance program to become a PAB herself.
If a resident has fallen, it’s supposed to be reported to the nurse before any attempt is made to lift them to avoid further injury.
But contrary to protocol, Costello said the day staff were not aware her grandmother had fallen until another resident told them the following day. There was also no handover note about the incident, said Costello.
Although the province publicly committed to improving the quality of care in CHSLDs following the COVID-19 pandemic, medical malpractice lawyer, Patrick Martin-Ménard, said in general, it’s still lacking.
Personnel shortages are often blamed, but Martin-Ménard said it goes deeper.
He says there is a culture of inattention and inadequate monitoring of elderly people who are often in fragile condition or at the end of their life.
Accidents are commonplace and protocols are not always respected, he said.
“I have a lot of respect for people who work in the health-care system, it’s very difficult conditions, it’s a very stressful environment,” said Martin-Ménard.
“Within the Quebec health-care system, there are often situations where people who are entrusted with vulnerable people do not take care of these vulnerable people as they should.”
That’s why there’s a need for strict monitoring to ensure accidents are kept to a minimum, he says.
He said it will be important to find out if the employee on shift the night of Geraldi’s accident was an employee of the CHSLD or a PAB from a private agency.
“Oftentimes when they appeal to people from agencies, there is an issue of training or proper familiarity with the existing protocols,” said Martin-Ménard.
At the end of 2023, Quebec passed a law that would gradually phase out the use of private agencies in both hospitals and CHSLDs by 2026.
Unlike nurses, PABs are not part of a professional order, says Natalie Stake-Doucet, a registered nurse who teaches full time at the University of Montreal’s nursing school.
Unless orderlies are trained by the head nurse or get formal training from the local health authority, she says they “don’t necessarily know exactly what to do.”
She said a fall is considered an accident, meaning the nurse in charge must be informed and an incident report filed. The report must include a physical evaluation of the patient she says, and involve the measures taken, such as informing the family or calling a doctor.
While Geraldi was generally happy with the care the staff provided at CHSLD Lasalle during the day and evening, Costello said her grandmother “dreaded” nights, as the facility was often short-staffed.
Costello said her grandmother complained about long waits to use the washroom and delays when calling for help to return to bed. These issues were raised with the care home’s administration at least five times, the last time, a couple months prior to her death, she says. But Costello says it didn’t really improve.
She suspects the CHSLD, which has 202 residents spread over three floors, was short-staffed the night her grandmother fell.
“You wish there was a camera in the room,” said Costello.
After Geraldi’s fall, a doctor ordered an X-ray at LaSalle Hospital the following morning. Rather than having her wait in a hospital hallway, Geraldi was sent back to her bed at the CHSLD until her transfer.
But by 6 p.m. on December 18, less than 24 hours after she fell, Geraldi died.
“It was so shocking,” said Costello. “She didn’t go a day without having a visit from somebody. And we had seen her the day prior, on the 17th. She was fine.”
Costello said she flagged the situation to the complaints commissioner at the CIUSSS de l’Ouest-de-l’Île-de-Montréal, which oversees CHSLD Lasalle, but isn’t hopeful it will lead to any meaningful change.
The CIUSSS de l’Ouest-de-l’Île-de-Montréal extended its condolences to Geraldi’s family.
In an email to CBC News, a spokesperson for the agency refused to comment on the case due to the ongoing investigations, and did not answer questions about whether the employee is still suspended or if any changes were made at the care home since Geraldi’s death.
Between March 2022 and April 2025, the CIUSSS de l’Ouest-de-l’Île-de-Montréal said there have been five complaints and three interventions made by the complaints commissioner related to negligence by the care home’s employees.
Late last month, the Service de police de la Ville de Montréal (SPVM) determined there was no criminal element involved in Geraldi’s death. As a result, the investigation is now solely in the hands of the coroner’s office which would only confirm that an investigation is ongoing.
Costello says her whole family is eagerly awaiting the coroner’s report, not only to get to the bottom of what happened and properly grieve, but to raise awareness about what’s going on in CHSLDs.
She worries about what is happening with residents who don’t have a support system or family who can advocate for them.
Through her own training as a PAB, she says not everyone is suited to the work.
She also knows that when a patient falls on your watch, it can be hard not to want to help immediately — even if that goes against procedure.
“But there’s a protocol. Just because someone has fallen does not mean you are at fault for it. But you are at fault if you make it worse,” said Costello.
