Deputy Health and Disability Commissioner Rose Wall today released a report finding a retirement village in breach of
the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of a man with a broken
leg.
The man was agitated and complained of pain in his upper thigh while at the Rowena Jackson Retirement Village. While a
caregiver reported the man’s pain to the registered nurse, the nurse failed to commence a pain assessment tool or pain
observation chart.
The following day, the man deteriorated and continued to complain of pain in his leg. A fax was sent to the GP for pain
medication, and a second fax requested the GP review the man’s condition. However, the GP did not receive the second fax
and no one at the village followed up with the GP. As a result, the GP did not attend the retirement village that day.
It was not until the day after, that the GP was contacted again. The GP then reviewed the man and discovered that the
man had not been weight-bearing for two days and diagnosed him with a fractured femur. The man was transferred to
hospital via ambulance.
The Deputy Commissioner found that Rowena Jackson Retirement Village did not provide appropriate care and services to
the man following the discovery of his leg pain.
"My report highlights multiple staff’s failures to use an appropriate pain assessment tool and monitor his pain
adequately," Ms Wall said.
"There was also a lack of urgency in obtaining a GP review, no referral or attempt to transfer the man to hospital was
made following the delayed GP review, and written communication with the man’s GP was inadequate," she said.
Ms Wall recommended that the retirement village audit compliance with its falls management plan and the use of a new fax
template and the amended fax referral document. The retirement village has apologised to the man’s family.
The full report on case 18HDC01735 is available on the HDC website.