Source: Health and Disability Commissioner
Rose Wall found they breached Right 4 – tautikanga; the right to services of an appropriate standard of care. She said the NP failed to assess, document and escalate management of the woman’s wounds appropriately – breaching the woman’s right to services provided with reasonable care and skill. In Bupa’s failure to follow up the woman’s referral to a wound clinic, and in not escalating her wound care to specialist services, it failed to provide the woman with quality care and continuity of services.
The NP has formally apologised to the woman and her whānau. She has also provided HDC with evidence of completing almost 130 hours of additional professional development including almost 40 hours focussing on wound management.
Ms Wall recommended the Bupa care home formally apologise to the woman’s whānau, and amend its policies to include clarification on when and how digital images are used to assess wounds; documentation of clinical discussions on wound management; escalation and referral processes for chronic wound management; and documentation of chronic wounds. She also recommended it consider making wound management course – Ko Awatea – compulsory for all registered nurses in parts of the country where the course is available.
The care home advised HDC that since these events it had ensured all registered nurses complete refresher wound care training, and has undertaken an audit on the skin assessment of residents. It has also supported those nurses who hadn’t undertaken Ko Awatea training to do so.
