Health Investigation – Rest home care provided to elderly woman

Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home and a nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failings in the care provided to an elderly rest home resident.

The woman had a number of health conditions and required supervision with some aspects of her personal cares. During her stay at the rest home, the woman had multiple clinical events, and her condition deteriorated in her final months. She was transferred to a public hospital and diagnosed with congestive heart failure and a respiratory tract infection. The woman died just over a week later, after being transferred to a private hospital for palliative care.

Ms Wall found that aspects of the care provided by the rest home were suboptimal, and that this meant that the woman was not managed appropriately and did not receive the specialist care she required in a timely manner. In addition, Ms Wall found a registered nurse had failed to provide appropriate oversight of the clinical documentation and to complete the necessary assessments and care plans for the woman. Ms Wall was also critical that the nurse did not respond to file notes regarding the woman’s concerning symptoms, and did not alert a GP to the woman’s deteriorating health in a timely manner.

Ms Wall was critical of the manager of the rest home for not providing appropriate oversight, not retaining copies of relevant clinical records, and the fact that staff were led to understand that he could provide clinical advice which fell outside the scope of his practice. Finally, Ms Wall was critical of a second nurse for not completing the woman’s care plan and assessments in a timely manner.

Ms Wall made a number of recommendations, including that the Nursing Council of New Zealand carry out a competency review of the first nurse and consider reviewing the second nurse’s competence and conduct. Ms Wall recommended the first nurse undertake further training and that both nurses and the rest home apologise to the woman’s family. Ms Wall acknowledged that the rest home had now closed, and therefore no recommendations could be made in relation to its service provision.

Ms Wall referred the rest home to the Director of Proceedings.

The full report for case 17HDC00655 is available on the HDC website.