Deputy Health and Disability Commissioner Rose Wall today released a report finding a residential aged care facility in
breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of an elderly
man who was paralysed and had dementia.
During the man’s admission to the facility, he developed serious pressure wounds, and required hospitalisation for
urinary tract infections. Sadly, he died approximately six months after admission to the facility.
The facility is owned and operated by Oceania Care Company Limited (Oceania). Previously the man had lived at home,
where his wife was his primary caregiver.
"Without appropriate support and interventions, the man’s health had the potential to deteriorate rapidly, and he was at
risk of developing complications," said Ms Wall.
The Deputy Commissioner found that a number of issues contributed to a failure to put in place effective actions to
prevent and manage the man’s serious pressure injuries and infections.
These issues included inadequate assessment and care planning for the man, a lack of initial consultation with his wife,
an interRAI assessment was not completed in a timely manner, and there was a lack of documented assessment of his
pressure injury risk or plans to mitigate that risk.
The Deputy Commissioner also criticised the facility’s Restraint Coordinator for allowing the use of a restraint (a
reclining arm chair) that was unsuitable for the man and was not an approved restraint in line with Oceania policy.
Ms Wall recommended that Oceania arrange training on resident care planning and pressure area risk assessment and
management; conduct an audit of completion of long-term person-centred care plans and monitoring forms; review its
restraint policy to provide guidance on pressure relief monitoring while restraints are in use; provide evidence that
the facility staff are aware of the statutory obligations for reporting pressure areas; and apologise to the man’s
family. Oceania was also referred to the Director of Proceedings.
The full report on case 18HDC01049 is available on the HDC website.