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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide appropriate care and services to one of its residents.
The elderly woman began suffering from vulvar pain and symptoms of a urinary tract infection during her stay at the rest home. The rest home did not initiate a short-term care plan, nor did it forward urine test results to the doctor. Soon after, the woman’s condition began to deteriorate and she developed a cough and nausea. The doctor prescribed nebulisers to relieve her coughing, however, nursing staff did not administer these as required.
Unfortunately, the woman’s condition continued to worsen and she was prescribed palliative medication, including medication to ease anxiety and nausea. However, the rest home did not prepare an end-of-life care plan, and the palliative medication was not administered until two hours after receiving the prescription. The woman died a short time later.
In her decision, Ms Wall concluded that the woman was “let down by various aspects of the care provided to her by numerous staff at the rest home during her stay.” She found the rest home had breached the Code by not preparing a short-term care plan in response to the woman’s change in status, not treating or assessing her vulvar pain adequately, not informing the doctor of her urinary test results, and not administering a nebuliser as required. In respect of the end-of-life care, Ms Wall felt there was a lack of planning and a delay in starting palliative medications. Ms Wall found the documentation by staff for this period to be poor.
Ms Wall recommended that the rest home apologise to the woman’s family, conduct an audit on a number of its policies and use the report as a basis for staff training.
The full report for case 17HDC02135 is available on the HDC website.