Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home and three of its nurses
in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to adequately manage
and assess a resident following two falls.
The woman, who had Alzheimer’s disease and dementia, fell twice while in the care of the rest home. Nursing staff
started neurological observations after each fall, but did not complete a 24-hour period of observations. Nursing staff
also did not calculate the woman’s Glasgow Coma Scale ("GCS") score, used to assess a person’s level of consciousness,
which was a requirement under the rest home’s policy.
Following the second fall, the woman went to sleep. When nursing staff woke her the next morning they found that she had
vomited and was less responsive. They called an ambulance, but did not describe the details of the fall or the head
injury to the dispatcher, and said that the woman was safe to wait for an ambulance if there was a delay. The woman’s
condition deteriorated and upon admission to hospital, it was found that she had suffered a brain bleed. Sadly, she died
a short time later.
Ms Wall considered that the rest home’s policy and documentation for neurological observations did not align with
national best practice, and rest home staff lacked understanding about the frequency or length of time for neurological
observations after a fall. She said the rest home failed to provide staff with appropriate guidance and training in
regards to neurological observations and falls.
Ms Wall was critical of three nurses who were on shift after the woman’s falls, for failing to undertake appropriate
neurological observations. Ms Wall also criticised one of those nurses for failing to commence a short term care plan or
inform the rest home’s facility manager after the second fall, and another of those nurses for not recognising a
possible severe head injury or informing the ambulance dispatcher that the woman required urgent medical attention.
Ms Wall recommended that the rest home and the three nurses provide written apologies to the woman’s family and that the
nurses involved undertake further training and education. Ms Wall made a number of other recommendations to the rest
home, including that it review its policies and arrange for further training for its staff.
The full report for case 17HDC01545 is available on the HDC website.