Care Provided To Unwell Man In A Rest Home

Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home company in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of a man admitted for respite care.

When the man, in his eighties, was admitted to the rest home, an enrolled nurse conducted his initial assessment and prepared his care plan. There is no documentation of the man’s baseline recordings having been taken at this point, or of his care plan being reviewed by a registered nurse.

The following morning, the man complained to a caregiver that he had abdominal pain and was unable to move, and he refused to go to lunch. The caregiver consulted the registered nurse (the rest home’s Clinical Manager and sole registered nurse) about the man’s refusal to go to lunch, but did not mention his abdominal pain. Later in the day, the registered nurse left the premises without having reviewed the man.

In the afternoon, the man’s daughter visited him at the rest home and found him to be very unwell. He was taken to hospital by ambulance, and on the way ambulance staff found his vital signs to be abnormal. The man was diagnosed with a perforation of his small intestine and, sadly, deteriorated in hospital and passed away the next day.

Deputy Commissioner Rose Wall found that aspects of the man’s care were inadequate, including his admission to the rest home and the failure of staff to escalate his abdominal pain to a registered nurse. Ms Wall was also critical of the registered nurse for failing to confirm the man’s admission documentation, and for not reviewing the man before leaving the premises.

"This case highlights the importance of aged care facilities ensuring that all new admissions are assessed by suitably skilled clinical staff in a timely manner," said Ms Wall. "The events… highlight how susceptible residents in aged care facilities are to a rapid deterioration in their condition. Both clinical and support staff need to think critically about a resident’s presenting symptoms, and provide appropriate intervention, including escalating concerns and seeking medical intervention as warranted."

Ms Wall recommended that the rest home company report back to HDC on changes to its practice; and review its assessment, management, and monitoring of pain policies, its training on orientation, its training to caregivers on illness assessment and communication, and its staffing levels around registered nurses. She also recommended the company provide a formal written apology to the man’s family.

The Deputy Commissioner recommended that the registered nurse undertake further education on the subject of delegating responsibility to staff, and apologise to the man’s family.

The full report for case 18HDC00217 is available on the HDC website.

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