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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 residential aged care provider in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide appropriate care to a man receiving hospital-level care at their facility.
The man, aged in his eighties, had been admitted to the facility for hospital-level care owing to his increasing care needs. During his six years at the facility, his health deteriorated, and he required interventions to manage his continence, hydration, medication, diabetes, podiatry, pressure areas, and pain.
Overall, there was a lack of attention and responsiveness to the man’s deteriorating condition by multiple staff, and a lack of oversight by the clinical managers. He was eventually transferred to hospital after two unsuccessful attempts to administer antibiotics, and he subsequently died as a result of septicaemia and facial cellulitis.
Ms Wall found that there were a number of failings involving multiple staff at the facility. The man’s continence care was not properly reviewed, his podiatry reviews were not arranged for him; his diabetes was not adequately monitored; and his pain relief was not properly managed. She was also critical of the inaccurate recording of the man’s wound care documentation and monitoring of the man’s pressure wounds, the failure to seek specialist advice in a timely manner, and the insufficient number of registered nurses available to provide oversight to junior staff.
“[The] provider had a duty to provide services [to the man] with reasonable care and skill, and is responsible for the actions of its staff,” said Ms Wall. “I consider that deficiencies in the care provided by multiple staff represent systemic issues at [the facility].”
Ms Wall recommended that the provider give training to its staff on pressure area prevention, pain management, and oversight by the clinical manager. She also recommended that it should audit compliance with policies developed in response to the complaint; review its staffing levels, induction and training programme, and equipment and supplies; and provide a formal written apology to the man’s family.
The Deputy Commissioner recommended that the clinical managers undertake training on clinical documentation, care planning and assessment, wound care management, communication, and clinical leadership; and that they provide written apologies to the man’s family.
The residential aged care provider has been referred to the Director of Proceedings.
The full report for case 17HDC00352 can be found on the HDC website.