Health Investigation – Care home fails to provide appropriate standard of respite care for palliative care resident. 20HDC01432

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Source: Health and Disability Commissioner
The Health and Disability Commissioner has found a care home breached the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide an appropriate standard of care to a respite patient.
The man, in his seventies at the time, had a complex medical history. He had been discharged home following hospital treatment for urosepsis, delirium and treatment for spinal cord compression, and was admitted to the care home, MLC 2011 Limited, for palliative respite care as his support needs were increasing.
The man’s family raised concerns in relation to the care he received during his week at the care home, including pressure injury and fluid intake management, as well as a medication error.
They also complained about the appropriateness of the meals, personal cares, responses to call-bell activation, and supervision of medication trolleys.
Aged Care Commissioner, Carolyn Cooper, noted that the man’s pressure injury management should have been supported by adequate and appropriate documentation, and that there were concerns with his hydration management and monitoring.
A medication error had occurred, although this was managed appropriately. While the man was becoming increasingly frail, given the cumulative nature of the issues with his care, she found MLC 2011 Limited breached Right 4(1) of the Code, the right to appropriate standards | Tautikanga.
Ms Cooper acknowledged that other issues raised by the man’s family were concerning and did not align with the family’s expectations of care delivery.
After a week-long respite admission at the care home, the man returned home. He was then admitted to a hospice and sadly passed away a few days later. Ms Cooper offered her condolences to the family.
The care home had since made several changes to its communication and documentation, and undertaken staff training.
Ms Cooper recommended that MLC 2011 Limited provide an apology to the family for the deficiencies in care highlighted in this report. As the residential care facility has changed ownership since the time of events, several recommendations were made for the new owners. These are outlined in the report. 

MIL OSI

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