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Assessment of rest home resident found outside (14HDC00471)
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(14HDC00471, 7 January
Registered nurse ~ Enrolled nurse ~ Rest home ~ Hypothermia
~ Nursing assessment ~ Right 4(1)
A registered nurse (RN) arrived to start her shift at a rest
home at around 7am, and found a male resident (aged 82 years) lying
on the grass outside. He was wearing only a thin pair of pyjamas,
which were damp from the dew, and he was cold to touch. He was also
barefoot and shivering. He told the RN he had been there for about
half an hour.
Other staff members came to assist, and the RN asked them to
return the man to his room and to get him warm and put him back to
At approximately 7.15am, the RN told staff to go to handover.
The RN went too, leaving two night shift caregivers to care for the
man. No RN assessment was carried out.
Following handover, the RN delegated care of the man's
observations to an enrolled nurse (EN), and asked her to record his
vital signs. At 7.30am, the EN took his vital signs. His
temperature was recorded as 34.4°C. The EN updated the RN about the
vital signs. The RN did not assess the man herself.
At around 8am, the man was found dead. The post-mortem report
concluded that he had died of hypothermia complicating pre-existing
ischaemic heart disease and chronic obstructive respiratory
By failing to recognise that the man had required a
comprehensive nursing assessment, for leaving two caregivers in
charge of his care and then delegating his assessment to an EN, and
for deciding it was appropriate for the EN to continue to monitor
the man even after the EN reported vital signs that suggested the
resident had hypothermia, the RN breached Right 4(1).
The rest home was not found to have breached the Code.