Night Checks On Patient At Mental Health Facility

Deputy Health and Disability Commissioner Kevin Allan today released a report finding a registered nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of a man at a residential mental health facility.

The nurse was rostered to work an overnight shift, from 11pm until 7am the following morning. As part of his overnight duties, he was to perform three site checks to ensure that residents were on site during the night.

The nurse performed the three site checks at 12.00am, 3.00am, and 6.00am. During the 3.00am check, the nurse performed the check by looking through the bedroom window through a gap in the closed curtains. He thought he could see the man sleeping, as there was a lump in his bed.

When the nurse performed the 6.00am check, it appeared that someone was still sleeping in the bed. However, when the nurse entered the room and pulled back the covers, the man was not there. At 7am that day, the man was found deceased off site.

Deputy Commissioner Kevin Allan was highly critical that the nurse omitted to perform the man’s 3.00am check adequately, and failed to sight the man physically. He also noted that on three separate occasions on the shift in question, the nurse provided inaccurate information in relation to the man - contradictory documentation regarding his night medications, documentation that the man was asleep at 12.00am when he was awake, and documentation that the man was asleep at 3.00am despite not sighting him physically. The Mental Health Commissioner considered these documentation deficiencies to be unacceptable.

"In the context of a high and complex needs mental health service, checks are required to ensure that the residents are safe," said Mr Allan. "It is therefore vital that residents are sighted physically to confirm their safety, and that these checks are performed adequately."

Mr Allan recommended that the nurse undertake training relevant to the issues raised in this case, organise for an experienced nurse to carry out a review of his documentation, and provide the man’s family with a written apology. He also recommended that the facility update its "Awake night shift" duties to include the need to sight the resident physically during the site security checks.

Mr Allan recommended that the Nursing Council of New Zealand consider whether a competency review of the nurse is warranted.

The full report for case 19HDC00276 is available on the HDC website.

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