Care of elderly woman in rest home 16HDC01013
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 failings in the care provided to an 87-year-old woman.
The report focused on the standard of care and nursing assessment provided to the woman over approximately seven months
during which time she became increasingly frail, had a non-healing pressure injury and experienced increased pain. When
she was transferred to hospital the woman was diagnosed with an ischaemic bowel and sadly, died a short time later.
Ms Wall found that the wound care provided to the woman, who had a very high risk of developing pressure injuries, was
not of an acceptable standard, and did not comply with the rest home policy on wound management. Ms Wall was concerned
by deficiencies in the assessment, evaluation, and documentation of the woman’s wounds by nursing staff, and the delay
in seeking specialist input. Ms Wall also considered that there was a lack of compliance with the rest home’s pain
management policy, and poor documentation in respect of the woman’s input and output.
"Poor record-keeping and poor compliance with policies and procedures amongst multiple staff members is indicative of an
environment that did not sufficiently support and assist staff in their duties," Rose Wall said.
She noted the rest home’s rosters confirmed low numbers of senior staff over the period of care investigated which she
considered was likely to have contributed to the deficiencies in care.
Further, Ms Wall stated that it was concerning that medical attention was not sought when the woman’s condition
Ms Wall recommended that rest home provide a written apology to the woman’s family. In recognition of the sale of the
rest home, it was recommended that the rest home owner satisfy itself that the deficiencies in the care identified in
this investigation are not of concern in other facilities it operates.
The full report for case 16HDC01013 is available on the HDC website