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 of a woman at risk of
weight loss.
The woman, aged in her sixties at the time of the events, had advanced Alzheimer’s disease and behavioural issues, which
placed her at risk of weight loss. She had been prescribed with six scoops of Ensure, an oral nutrition supplement, to
be taken three times a day. During her time at the rest home, some nursing staff were confused by the woman’s
prescription, and on occasion she was administered one "scoop" of the product instead of the prescribed one "dose",
which was six scoops.
Over a four-month period, the woman lost just under 10 kilograms of weight. This should have triggered multiple
follow-up actions (such as a referral to a nutritionist), as per the rest home’s weight loss assessment and management
policy. However, timely action and appropriate follow-up did not occur.
Deputy Commissioner Rose Wall was critical of multiple failures by the rest home. These included not ensuring that a
complete care plan was prepared to guide staff when the woman was admitted to the rest home, and the failure of multiple
staff to administer the woman’s Ensure in accordance with her prescription. Staff also failed to seek clarification of
the prescription in a timely manner and to act on evident weight loss, despite it being recorded monthly.
The Deputy Commissioner considered that the number of staff involved in the inadequate care provided to the woman
suggested a lack of staff understanding of the rest home’s expectations, a lack of critical thinking, and a lack of
oversight by the rest home.
"In my view, the widespread and repeated nature of the omissions reflects a pattern of poor care and failure to comply
with policy, for which ultimately [the rest home operator] is responsible," said Ms Wall.
The Deputy Commissioner recommended that the rest home operator provide training to all nursing staff on care planning
requirements; monitoring and managing residents’ nutritional needs; administering medication; and the professional
responsibility of nursing staff to question ambiguities and raise concerns.
Ms Wall also recommended that the rest home operator consider whether any of the learnings from the HDC’s investigation
can be translated into improvements throughout its other aged-care services; undertake an audit to confirm compliance
with its weight loss policy; and provide the woman’s family with a written apology.
The full report for case 19HDC01030 is available on the HDC website.