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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 failures in the pressure wound care and pain management of an elderly woman.
The woman, aged in her eighties at the time of her admission to the rest home, was frail and had dementia. During her time at the rest home, it was discovered that she had pressure wounds. There is no documented evidence that she was turned regularly every two hours following the discovery of these wounds, or that her wounds were dressed daily as instructed by her general practitioner (GP). Rest home staff did not seek a review or assistance from the wound care specialist or the GP until around two months after the wounds were discovered, and the observations and progress of the wounds were not documented appropriately.
The woman’s first pain assessment was conducted six weeks after the discovery of the pressure wounds, and her pain was not assessed at every wound dressing in accordance with the rest home’s wound policy. The rest home also did not administer morphine regularly or consistently when the woman was in pain, or when her dressing was changed.
Deputy Commissioner Rose Wall found that the rest home did not provide appropriate care for the woman’s pressure wounds, or adequately manage her pain. She was also critical that the rest home did not keep the woman’s family updated and fully informed about the woman’s deteriorating wounds, and was concerned by the lack of clear guidance as to who had the overall responsibility of the Clinical Services Manager role at the rest home.
“[The woman] was let down by various aspects of the care provided to her by numerous staff at the rest home,” said Ms Wall. “The problems that arose with [the woman’s] care were not the result of isolated incidents involving one or two staff members, but are attributable to several registered nurses, healthcare assistants, and clinicians who provided care to [the woman] during her stay at the rest home. In my opinion, this indicates failures at a systemic and organisational level.”
Ms Wall recommended that the rest home conduct an audit of staff compliance with its policies; conduct an audit of wound documentation for 10 residents; report back to HDC regarding the implementation and effectiveness of the changes made; and apologise to the woman’s family.
The full report for case 18HDC01213 is available on the HDC website.