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 failing to provide appropriate care and services to one
of its residents.
The elderly woman began suffering from vulvar pain and symptoms of a urinary tract infection during her stay at the rest
home. The rest home did not initiate a short-term care plan, nor did it forward urine test results to the doctor. Soon
after, the woman’s condition began to deteriorate and she developed a cough and nausea. The doctor prescribed nebulisers
to relieve her coughing, however, nursing staff did not administer these as required.
Unfortunately, the woman’s condition continued to worsen and she was prescribed palliative medication, including
medication to ease anxiety and nausea. However, the rest home did not prepare an end-of-life care plan, and the
palliative medication was not administered until two hours after receiving the prescription. The woman died a short time
later.
In her decision, Ms Wall concluded that the woman was "let down by various aspects of the care provided to her by
numerous staff at the rest home during her stay." She found the rest home had breached the Code by not preparing a
short-term care plan in response to the woman’s change in status, not treating or assessing her vulvar pain adequately,
not informing the doctor of her urinary test results, and not administering a nebuliser as required. In respect of the
end-of-life care, Ms Wall felt there was a lack of planning and a delay in starting palliative medications. Ms Wall
found the documentation by staff for this period to be poor.
Ms Wall recommended that the rest home apologise to the woman’s family, conduct an audit on a number of its policies and
use the report as a basis for staff training.
The full report for case 17HDC02135 is available on the HDC website.