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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 an enrolled nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of an elderly man at a rest home.
The man, in his seventies at the time of events, had dementia and Parkinson’s disease and was at risk of falling. He lived in the rest home’s secure dementia unit. An interaction between the man and the nurse resulted in the man falling, which was recorded on CCTV. The nurse did not complete an incident form, and did not identify corrective actions to prevent or minimise a recurrence.
The CCTV footage has no audio, and the visual quality is poor. It shows the nurse inside the nurses’ station during handover. The man is seen standing at the internal window at the nurses’ station with both hands on the window sill, while the nurse remains inside the station.
The nurse appears to touch or pick up the man’s hands and then what happens next in the footage is open to interpretation. The man then loses his balance, stumbles backwards and falls heavily.
Deputy Commissioner Rose Wall considered that the footage demonstrated that the nurse’s management of the man’s behaviour was inappropriate and not consistent with his needs. She was also critical that the nurse did not complete all required actions following the incident.
The rest home was not found in breach of the Code, and it was noted that appropriate action was taken by staff to investigate the incident and advocate on behalf of a vulnerable consumer.
“[The man] was a particularly vulnerable consumer who was put at risk of injury as a result of the deliberate actions of a single staff member who was responsible for his care and well-being and, above all else, should have been keeping him safe,” said Ms Wall.
Ms Wall recommended that the nurse participate in further training related to dementia and behavioural challenges, and provide a letter of apology to the man’s family. She also recommended that the Nursing Council of New Zealand consider whether a review of the nurse’s competence is warranted.
To read the full report on case 19HDC01185, visit the HDC website.