Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home operator in breach of
the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care provided to an elderly
woman.
The woman was discharged from a lengthy stay in hospital to rest-home-level care at a facility run by the rest home
operator. Staff at the rest home were concerned that the woman required a higher level of care than rest-home-level,
owing to her medical problems and assistance requirements. However, they did not take steps to initiate a change in her
care level. There were also issues with the woman’s initial care planning at the time of her admission.
The woman’s condition deteriorated while she was at the rest home and, after seven days at the home she was transferred
back to hospital, where she was diagnosed with sepsis secondary to cellulitis. Sadly, she died the following day.
Deputy Commissioner Rose Wall considered that there were serious issues with the planning of the woman’s care at the
rest home, and attributed these to the rest home operator. She found that the woman did not have a clear initial care
plan to guide nursing staff in providing coordinated care in light of her multiple medical problems; no steps were taken
to have the woman reassessed for a higher level of care; and staff were not proactive in obtaining the discharge summary
or assessment from the district health board (DHB).
The Deputy Commissioner was also critical that on discharge from the DHB, the woman was assessed as requiring
rest-home-level rather than hospital-level care.
"[The rest home operator] had an organisational duty to provide services to [the woman] with reasonable care and skill,"
said Ms Wall. "Multiple nursing and caregiving staff were involved in [the woman’s] care. Overall, I consider that [the
operator] holds primary responsibility at a systems level for the poor standard of care provided."
Ms Wall recommended that the rest home operator arrange further education for its staff on initial assessment and care
planning, decision-making and early intervention for deteriorating patients, and management of cellulitis. She also
recommended that the rest home use a standard form to document handovers from the DHB, and take steps to ensure that its
staff are clear on the process required for timely reassessment of a resident if a higher level of care is needed.
Finally, Ms Wall recommended that the operator review its policies and procedures around managing a resident who
requires a higher level of care, and provide an apology to the woman’s family.
The Deputy Commissioner recommended that the DHB prepare an anonymised case study to share with staff involved in
discharge planning, for educational purposes.
The full report for case 19HDC00340 is available on the HDC website.