Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home in breach of the Code of
Health and Disability Services Consumers’ Rights (the Code) for failures relating to care provided to an 86-year-old man
with a high falls risk.
Although it was identified on admission that the man had a high fall risk, he sustained 97 documented falls during a 10
month period. Ms Wall found that although interventions were put in place to manage his risk of falling, they were not
successful and that the rest home’s management of the man’s falls risk was inadequate.
"While some interventions were implemented and some reviews were completed, there was no detailed analysis of the data
collected about his falls," Rose Wall said.
Inadequate supervision was found to have been an issue on one day in particular. On this day staff repeatedly observed
the man attempting to get outside so he was taken for a walk. However, following this walk he was left unsupervised and
was later found on a road near the rest home. Although he was returned once found, he left for a second time 10 minutes
later after being left unsupervised again.
"That he was able to leave on two occasions within minutes suggests that rest home staff did not supervise the man
adequately on that day," Rose Wall said.
Ms Wall made a number of recommendations in relation to the rest home. Firstly, that they provide evidence that their
policies and procedures on falls management, incident reporting, client assessment, and care planning are current and
reflect best practice. Secondly, that they provide evidence of undertaking audits to assess compliance with their
policies and procedures. Finally, Ms Wall asked that the rest home apologise to the man’s family for the deficiencies
outlined in the report.
The report for case 16HDC01581 is available on the HDC website