Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home provider and two
registered nurses in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in
the care of a rest home resident.
The woman, aged in her nineties, moved into a rest home with a hospital wing because she was unable to cope by herself
in her own home. She had a history of worsening dementia and hypertension, and a past history of bowel cancer.
Initially, the woman was placed in a unit in the rest-home wing, but she was transferred to the hospital wing after she
was reassessed as requiring level 5 hospital care (very high assistance) owing to her worsening dementia and difficulty
with incontinence, toileting and self-cares.
The woman became unwell, and her condition deteriorated over the course of five days. Staff at the rest home failed to
identify and respond appropriately to the woman’s deterioration over this period.
On the fifth day, the woman was transferred by ambulance to a public hospital. She was assessed in the Emergency
Department and noted to be short of breath with an audible wheeze and visible accessory muscle use, indicating that she
was working hard to breathe. She was found to have widespread wheeze/crepitations in both lungs.
Initially she was thought to have a chest infection and was started on antibiotics. However, later she was diagnosed
with a large pulmonary embolism with associated heart strain. The woman remained in hospital for eight days, after which
she was discharged back to the rest home. Sadly, she died a few weeks later.
Deputy Commissioner Rose Wall identified a number of failures in the services provided by the rest home provider. These
included a lack of critical thinking by multiple staff, a failure by staff to comply with policies and procedures, and
inadequate communication with the woman’s family.
Ms Wall also found two registered nurses in breach of the Code: one for failing to use appropriate care and skill when
assessing the woman’s health needs, and the other for failing to ensure that the woman was provided with services of an
appropriate standard. She was also critical of another nurse’s delay in arranging the transfer to hospital.
"Rest-home residents are vulnerable, and often without the ability to advocate for themselves," said Ms Wall. "They
therefore rely on staff to provide adequate care, and speak up for them when they have concerns. In [the woman’s] case,
it was only after the family continued to question staff and then request action that [the woman’s] care was escalated
appropriately."
Ms Wall recommended that the rest home provider outline the steps it has undertaken to ensure timely clinical review and
transfer of residents to hospital, and use this case to provide education to nursing staff at its facilities. She also
recommended it undertake a review of cases where residents have either been referred to the GP for urgent review or
transferred to hospital, and an audit to ensure staff compliance with the oxygen administration policy.
Ms Wall recommended that the provider and the nurses involved provide formal written apologies to the woman’s family.
The full report for case 17HDC01706 is available on the HDC website.