Failure to provide appropriate care to rest home resident 17HDC02219
Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home owner in breach of the
Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide appropriate care to a
In 2016 a woman in her 90s was discharged from a public hospital and admitted to hospital-level care at the rest home.
The woman had a long-term indwelling catheter (IDC) in place, and was unable to weight bear to mobilise. She required
two-person assistance and a full sling hoist for all transfers. On admission she was assessed as being at high risk of
developing pressure sores, and her perineal and sacral areas were evaluated by nursing staff regularly over a four-month
period. There were a number of documented issues with her catheter, including dislodgement of the catheter, leaking of
the catheter and catheter bag, and urinary tract infections.
In early 2017 it was found that the skin on the woman’s sacrum had broken down, and a GP arranged for her to be
transferred to hospital for review. Sadly the woman died the following month after a period of ill health.
The Deputy Commissioner was critical that incidents occurred that showed a lack of knowledge and skill regarding IDC
cares by staff at the rest home. Ms Wall was critical that multiple staff did not adhere to the care plan and the rest
home’s policy about catheter care. She was also critical that the rest home did not provide adequate further education
to its staff on IDC management sooner, despite being aware of ongoing issues with staff skill in relation to the woman’s
IDC early in her time at the rest home.
Ms Wall was also critical that hoist and transfer training did not occur more promptly and that a referral to a wound
care specialist did not occur in a timely manner. She was also critical that temperatures recorded at the rest home did
not comply with the rest home’s policy relating to comfortable temperature.
The woman’s son held an activated Enduring Power of Attorney for his mother’s health and well-being. He was very
involved in his mother’s care and on multiple occasions he raised concerns with rest home staff about the care.
Ms Wall highlighted the importance of a good relationship between staff and family to deliver good care to residents in
residential aged care settings. She considered that the rest home should have been more proactive and should have
requested external support to guide its staff and support the woman’s son.
Ms Wall recommended that the rest home owner apologise to the woman’s son. She also recommended they provide training to
staff, audit policy compliance and share her report among their other care homes.
The full report for case 17HDC02219 is available on the HDC website