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Rest Home Care Of Woman At High Risk Of Falls

Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home and a healthcare assistant (HCA) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care provided to an elderly woman.

The woman, aged in her eighties, had advanced dementia, was unsteady on her feet, and was prone to falls. Her care plan noted that she was a high falls risk, and that she required two-person assistance when mobilising.

One evening, the HCA transferred the woman to her room without assistance. During the transfer, the woman suffered a fall and remained on the floor for seven minutes. She was left alone while the HCA went to seek help. Following the fall, the HCA showed no sense of urgency or concern for the woman’s immediate safety and well-being, and little compassion or empathy toward the woman. She did not hold the woman’s hand or maintain any physical contact. While the woman was on the floor, her dress remained up past her knees, and she was not provided with a pillow, a blanket, or any other physical means of comfort until the registered nurse arrived.

On the evening in question, staffing shortages meant two HCAs were providing cares to all 20 residents in the woman’s wing of the rest home, and two registered nurses attending to all 70 residents at the home. The HCA had not undergone recent training on falls management or dementia care, and the rest home could not provide any evidence of the HCA’s dementia-specific training during her employment at the home.

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Deputy Commissioner Rose Wall was critical of the poor judgement displayed by the HCA in deciding to transfer the woman alone, and that she did not take extra care during the transfer. She also found that the HCA failed to respect the woman’s dignity after the fall.

Ms Wall found that the rest home did not provide appropriate care and services to the woman by failing to have adequate staffing levels on the night of her fall, and failing to provide adequate training to its staff. The rest home’s falls policy was also found to be inadequate. She also found the rest home did not seek a timely GP review.

"[The woman] had complex care needs owing to her advanced dementia and limited mobility and communication ability," said Ms Wall. "She was reliant on staff to provide all her cares and, as such, she was a particularly vulnerable consumer… [The rest home] has an obligation to ensure that its care staff have sufficient training, and that the staffing levels are adequate at all times, in order to support the staff in their roles. It is apparent that there were shortfalls in both of these areas, and that this had a negative impact on the care provided to [the woman]."

The HCA has since undergone dementia-specific training. Ms Wall recommended that the HCA review an article on the role of empathy and report to HDC with her learnings, undergo further falls training, and apologise to the woman and her family.

Ms Wall recommended that the rest home report back to HDC on the findings from a DHB inquiry into the home, a surveillance audit, and on steps taken to address staff shortages. She also recommended the rest home review its staff training records and its falls policy, and apologise to the woman and her family.

The full report for case 19HDC00504 is available on the HDC website.

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