A man in his nineties was a resident in the retirement village’s special care dementia unit. The report concerns the
nurse’s response to the man’s challenging behaviours during an incident in May 2020, where the man was found by a
healthcare assistant (HCA) to be having an altercation with another resident. The HCA was unable to remove the man by
herself and pressed the call button for help. This call resulted in no response, so the HCA had to run out of the room
to seek help. The nurse, who was the duty charge nurse, responded and proceeded to shout and speak to the man in a
disrespectful manner, and forcefully removed him from the room.
Following the incident the nurse told the healthcare assistant that she would complete the "behaviour chart" in regard
to the incident and a challenging behaviour report in line with the village’s policies. However, these were not done,
neither was the incident escalated to the village manager.
The families were also not informed of the incident. It was not until the village manager visited the special care unit
several days later and noticed bruising on the man’s face (from the altercation with the other resident) that further
action was taken to understand what had happened.
In addition, Rose Wall considered that the nurse failed to provide services to the man with reasonable care and skill,
as she did not ascertain whether assistance was needed from her when the patient’s call bell was activated by the HCA,
she failed to wear a mask during a COVID-19 outbreak in the country, she did not complete the required clinical
assessments, and she failed to escalate and report the incident as per the retirement village’s policies. In addition,
the nurse did not contact the patient’s GP, or Enduring Power of Attorney (EPOA) about the event,
The incident highlights the importance of treating vulnerable patients with respect, taking appropriate actions after an
event in line an organisation’s policies, and providing good communication with a patient’s family.
Ms Wall also referred the nurse to the Director of Proceedings to decide whether proceedings should be taken.
The full report of case 20HDC01228 is now available on the HDC website.