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Care Of Rest-home Resident With Pressure Injuries

Deputy Health and Disability Commissioner Rose Wall today released a report finding G J & J M Bellaney Limited in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for its failures in its care for a man in his eighties.

The man, who had a number of serious health conditions, required dementia level care. Over the course of two months the man had two falls and developed pressure injuries. There were a number of oversights in the man’s care relating to communication, and the management and documentation of falls and pressure injuries, which resulted in the pressure injuries not being well managed and the man’s family not being kept informed. When the man was transferred to hospital level care, the rest home failed to document the extent of the pressure injuries to the new provider.

Ms Wall found that G J & J M Bellaney Limited failed to provide services to the man with reasonable care and skill. She highlighted the importance of providers communicating effectively with one another and with the consumer’s family, and of ensuring that clinical assessments and care plans are comprehensive and actioned, and that documentation is completed to a good standard to support care and decision-making, including on the transfer of care to another provider. Accordingly G J & J M Bellaney Limited was found to be in breach of the Code.

Ms Wall noted that the man’s family were very involved in his care and would have expected pertinent information to be conveyed to them. She said "I consider that information pertaining to a change in health condition, such as falls and pressure areas, is significant, and information that a family would expect to receive. I am critical that this did not occur".

Ms Wall recommended that G J & J M Bellaney Limited apologise to the man’s family which has been done. Ms Wall’s other recommendations included that the rest home consider gaining access to a more specialised level of nursing, clarify guidelines for accessing specialist advice, schedule regular and ongoing education sessions on specified topics and report back to HDC on the effectiveness of these changes and the results of audits in relation to the changes.

The full report for case 18HDC01024 is available on the HDC website

https://www.hdc.org.nz/decisions/search-decisions/2020/18hdc01024/

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