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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 provider and two registered nurses in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of an elderly resident.
The man, aged in his eighties at the time of events, had multiple existing health conditions and was prescribed morphine for worsening pain. One morning, a registered nurse and two caregivers were on duty. None of these staff members had met the medication competency requirements set out in the rest home’s Medication Management policy. Medication competency was a requirement before staff were allowed to administer stock-controlled medications such as morphine.
During the shift, the nurse was told that the man appeared to be distressed. She drew up 2.5ml of subcutaneous morphine solution without checking the prescribed route of administration or calculating the dose. The solution administered to the man contained 25mg of morphine, which exceeded the maximum quantity prescribed by a factor of five. The nurse administered the solution orally early in the morning. In the early afternoon, it was reported that the man was unresponsive, and he sadly died that evening.
Deputy Commissioner Rose Wall found the rest home provider failed to provide the man with a service from suitably qualified/skilled and/or experienced service providers, and failed to ensure that the systems in place were sufficiently robust to ensure that all staff complied with the Medication Management Policy. Ms Wall was also critical that the rest home disclosed the medication error to the man’s family members and his Enduring Power of Attorney before consulting with the executor of his will.
Ms Wall found the nurse in breach of the Code for administering medication without checking the appropriate route or calculating the appropriate dosage. She found another nurse in breach of the Code for not ensuring that sufficient medication-competent staff were rostered on duty, as required by the Medication Management Policy.
“I am concerned that at the time of these events, the systems in place at Molly Ryan were not sufficiently robust to ensure that all staff complied with the Medication Management Policy,” said Ms Wall. “Medication-competency training had not been fully completed by staff with responsibility for medication management before they were rostered on duty and, as such, the staff concerned were not supported to administer medication safely, and were not suitably skilled to deliver the standard of care required.”
Ms Wall’s recommendations included that the rest home provider audit every shift for a month to ascertain whether at least two medication-competent staff members were on duty, and report any medication errors to HDC for three months, together with a root cause analysis and mitigation strategies. She also recommended that the provider review its Medication Administration Policy and its system and process for inducting nurses and signing off medication competency; use HDC’s report as a basis for staff training; and provide a formal apology to the man’s family, which has been done.
The Deputy Commissioner recommended that the first nurse provide a written apology to the family, and that the Nursing Council of New Zealand review her competence should she return to practice in New Zealand. She recommended that the second nurse provide a written apology to the man’s family, and report to HDC on the changes she has instigated to her practice as a result of this case.
To read the full report on case 19HDC01150, visit the HDC website.