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Assessment, monitoring and evaluation of nutritional status and sacral pressure ulcer (11HDC00471)

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(11HDC00471, 25 June 2013)

Aged care provider ~ Registered nurse ~ Systems issues ~ Clinical decisions ~ Communication ~ Staff training and supervision ~ Right 4(1)

An 84-year-old woman, whose medical history included Parkinson's disease, dementia, osteoporosis, recurrent urinary tract infections, postural hypotension, type II diabetes, incontinence and poor vision, was resident in an aged care facility. The woman was found to have a pressure ulcer on her sacrum. This was managed with bed rest, use of an air mattress, regular dressing changes and two hourly turns.

Although the registered nurses (RNs) responsible for the woman's care monitored and treated the sacral ulcer, it progressively deteriorated. During this time, the woman's weight was decreasing and she was assessed as requiring referral to a GP or dietitian for input into her nutrition. Although the RN hospital manager and RN clinical manager were aware of the woman's sacral ulcer, they did not assess or evaluate the woman's condition over the next four months.

When the GP saw the woman for a routine three-monthly review, he noted that she had a very deep necrotic 3cm diameter sacral pressure ulcer which had slowly increased over the last five months. Swabs were taken for laboratory analysis, but no other changes to the treatment plan were made. A week later the RN hospital manager made a request for an urgent referral of the woman to a large public hospital for surgical treatment of the sacral ulcer given the ulcer's worsening condition. This request was supported by the GP. The woman was admitted to hospital, and following an assessment of her condition, the decision was made that palliative care was the preferred option. The woman died a short time later.

It was held that the aged care provider did not take sufficient steps to ensure the woman was provided with services of an appropriate standard. Several RNs were responsible for caring for the woman and for the assessment, monitoring and evaluation of her nutritional status and sacral pressure ulcer on a continuous basis. The ulcer was clearly deteriorating over a three month period, but none of the RNs properly assessed or evaluated the woman's ulcer, the effect that her nutritional status was having on the healing of the ulcer, or sought specialist advice. There was a lack of communication between the RNs, the hospital manager, and the clinical manager about the woman's ulcer. Staff did not communicate effectively with the woman's family about her status. The aged care provider breached Right 4(1).

Both the hospital manager and the clinical manager were responsible for ensuring that the care provided to the woman was of an appropriate standard. The hospital manager breached Right 4(1) for failing to review the woman's nutritional status and ulcer, failing to evaluate the wound assessment plan, and failing to consider whether the woman's nutritional status was affecting the healing of the ulcer. The clinical manager also breached Right 4(1) for failing to review the woman's ulcer or clinical notes at any time and for failing to evaluate the wound assessment plan.

Adverse comment was made regarding the GP's lack of review of the woman's pressure ulcer.

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