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Rest Home’s Failure To Care For Elderly Woman

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 of an elderly woman.

The woman stayed for a short time at the rest home while awaiting a definitive care plan to manage fractures in her upper arm.

On day eight of her stay at the rest home, she was transferred to the public hospital via ambulance as her condition had deteriorated, and she had severe pain and dehydration. Sadly, four days later she passed away from intra-abdominal sepsis.

The Deputy Commissioner found that Bupa Care Services NZ Limited breached the Code for the lack of assessment and care planning by a registered nurse at the time of the woman’s admission.

Ms Wall said there was a lack of direction and clear documentation to allow care workers to provide safe, effective care for the woman’s fractures. The rest home failed to undertake a pain assessment and, inconsistently and inappropriately used pain relief despite her uncontrolled pain and nausea.

The Deputy Commissioner also found the rest home in breach of the Code for failure to administer laxative medications; failure to undertake a formal nursing assessment, develop a relevant short-term care plan, or seek medical review after the woman was noted to have a UTI, or after she demonstrated a clear deterioration in her condition. Ms Wall was also critical of Bupa’s management of the woman’s continence and for the call bell being left out of her reach on a number of occasions.

Ms Wall recommended that Bupa Care Services NZ Limited undertake a three-month audit on a number of matters, including to confirm that relevant admission assessments have been completed by a registered nurse.

Ms Wall also recommended that the rest home use the findings of this complaint as a basis for training staff at its facilities; schedule education sessions on various relevant topics for all its rest home nursing staff; review and update its "Short Stay - Residents" policy for accepting a patient from hospital and discharge information required on transfer; and provide a written apology to the woman’s family.

The full report on case 18HDC01941 is available on the HDC website.

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