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Elderly Man Suffered Two Falls At Rest Home

Deputy Health and Disability Commissioner Rose Wall today released a report finding rest home owners Oceania Care Company Limited in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of a man who suffered two falls.

The man had a medical history of poor balance, severe fatigue, impaired hearing and end-stage renal failure. At the time of events the man had been a resident at the rest home for only five days.

The first fall occurred when a staff member helped the man to the toilet, and left him alone. The second fall occurred when the man fell out of bed and onto the floor when reaching for something on his bedside table. The man was later diagnosed with a fractured right ankle, and sadly died a week later.

At the time of the incidents the rest home was owned and operated by Oceania Care Company Limited (Oceania). It has since been sold to another company.

The Deputy Commissioner found there were serious issues with the care the man received at the rest home, including a lack of critical thinking around the man’s risk of falling by the multiple rest home staff who cared for him.

Ms Wall found the call-bell system was faulty and this wasn’t communicated to staff, nor was a temporary workaround implemented. She also found there were discrepancies in multiple aspects of staff documentation of the man’s care after his falls.

"In my view, Oceania had the ultimate responsibility to ensure that the man received care that was of an appropriate standard and complied with the Code. Overall, there were serious issues with the care he received at the rest home," said Ms Wall.

The Deputy Commissioner recommended that both Oceania Care Company Limited provide the man’s family with a written apology.

Ms Wall made a number of recommendations to the current rest home owners, including that they share HDC’s anonymised opinion with nursing and care staff for educational purposes; and complete a review of the last ten newly admitted patients to hospital-level care to ensure that staff are completing appropriate assessments and care plans where indicated.

She also recommended that they review registered nurses’ and healthcare assistants’ documentation of fall incidents; and ensure there are appropriate protocols in place to ensure staff are fully aware of the mobility and toileting requirements of hospital-wing residents at the beginning of each shift.

The full report on case 19HDC00603 is available on the HDC website.

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