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Care of rest-home resident with leg ulcers 16HDC01437

Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care for a woman in her seventies.

The woman was discharged from a public hospital to the rest home as she required long-term hospital-level care. She had high and complex needs that predisposed her to wounds and had multiple existing ulcers when she was admitted to the rest home.

During her time there, she developed further wounds which were not appropriately assessed or cared for. Her wounds were allowed to progress to such a degree that they were significantly infected and some had maggots. After about six months the woman became acutely unwell and was admitted to a public hospital where she was diagnosed with sepsis secondary to infected ulcers, and passed away.

Ms Wall said it was critically important that rest home staff were attentive to the woman’s needs and responded accordingly. She found that while at the rest home the woman did not receive appropriate assessment and care of her numerous wounds, or appropriate management of her pain.

"She would have experienced significant pain as her condition deteriorated which could have been avoided had her pain been managed more effectively," Ms Wall said.

Ms Wall found the rest home failed to provide services to the woman with reasonable care and skill with regard to her wound care, documentation and assessment, reporting processes, oversight of her overall condition, pain management, and GP and specialist referral. Accordingly the rest home was found in breach of the Code.

The rest home was sold and Ms Wall recommended that the new owners report back to HDC on its compliance with appropriate policies and documentation, and further training for staff. The previous owners were asked to apologise to the woman’s family.

The full report for case 16HDC01437 is available on the HDC website.


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