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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 assisted living facility and nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of a woman who suffered burns.
The woman lives with spastic quadriplegia and does not communicate verbally. While she was resident of the community home owned by St John of God Hauora Trust, there were several oversights in the management of her continence products, including the delay in monitoring and replacing them for 12 hours.
Subsequently, it was discovered the continence product leaked, and that she sustained burns to both thighs.
There was also a lack of frequent pain assessments, inadequate medication administration, inconsistent documentation, a failure to seek timely medical review, and insufficient communication with the woman’s welfare guardian.
The Deputy Commissioner found St John of God Hauora Trust failed to provide services with reasonable care and skill, and in a manner that respected the woman’s dignity.
She also found the Community Homes Manager, an enrolled nurse, failed to seek clinical advice from a registered nurse, and provided insufficient guidance to staff when the burns were reported to her.
“My report highlights the importance of service providers having robust policies and procedures in place to support staff in caring for particularly vulnerable residents,” Ms Wall said.
Ms Wall recommended that St John of God Hauora Trust provide evidence that the recommendations set out in its internal investigation have been implemented; consider implementing a handover tool to ensure that relevant information is communicated; undertake an audit of its Medication Administration Records; undertake an audit to confirm that adequate continence product supplies are being maintained; consider reviewing the adequacy of its process in place for sourcing medical care; and provide a written apology to the woman.
She also recommended that the enrolled nurse provide a written apology to the woman, and that the Nursing Council of New Zealand consider whether a review of the enrolled nurse’s competence is warranted.
The full report is available on case 19HDC01464 is available on the HDC website.