Recognition And Management Of Deterioration In A Rest Home Patient

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 failing to appropriately manage a woman’s care when her condition rapidly deteriorated.

Over a period of four days, the woman experienced confusion, constipation, pain and urinary incontinence. She was admitted to hospital after she lost consciousness and, sadly, she died from sepsis and cellulitis.

The Deputy Commissioner found there was an overall lack of response to the woman’s declining condition, despite the woman’s medical history suggesting that she was likely to experience a progressive decline in her general function.

"The various nursing staff involved in her care should have been alert to changes in her condition, and reacted more rapidly to new symptoms as they manifested," Ms Wall said.

Ms Wall also found that although the woman was diabetic, staff did not assess her blood sugar levels, and that the rest home failed to contact a doctor earlier in response to the woman’s confusion and deterioration. There were also missed opportunities for the rest home to take into account concerns raised by the woman’s daughter.

Ms Wall was critical of a nurse for failing to manage the emergency situation appropriately when the woman lost consciousness.

Rose Wall recommended that the rest home provide a written apology to the family, schedule specific education sessions for the facility’s nursing staff, use an anonymised version of this case as a case study to encourage staff reflection and discussion, and review its policy on clinical emergencies.

The full report for case 17HDC01279 is available on the HDC website. https://www.hdc.org.nz/decisions/search-decisions/2020/17hdc01279/

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