Deputy Health and Disability Commissioner Rose Wall today released a report finding the owner of a rest home in breach
of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures relating to the care of a woman
in her eighties with a number of serious medical conditions.
The woman was a permanent resident of the rest home. She was initially classified as being a low falls risk, however she
fell five times within a two month period.
A number of nurses caring for the woman did not comply with organisational policies for the management of falls and
falls risks.
Ms Wall was critical that the woman’s health status, including her risk of falls, was not appropriately reviewed. Ms
Wall was also critical that there was inadequate consideration and implementation of preventative measures.
The woman had another fall, which resulted in serious injuries. Ms Wall was critical that, following this fall, the
woman was provided with inadequate pain relief and there was an inappropriate delay of three days before the woman was
assessed by a doctor.
Ms Wall considered that the failures by numerous rest home staff demonstrated a pattern of poor care, poor compliance
with policy, and a lack of critical thinking.
Ms Wall recommended that the rest home owner apologise to the woman and her family. She also recommended that they
develop an assessment tool for following up a resident who has fallen and provide evidence of training in relation to
falls. As the ownership of the rest home has changed since these events, the new owner of the rest home was asked to
share the report with staff and consider what could be learnt from it and applied to its own policies and procedures.
The full report for case 17HDC01304 is available on the HDC website.
ENDS