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Care and communication at rest home (11HDC00812)
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(11HDC00812, 11 October
Rest Home ~ Registered nurse ~ Wound care ~ Medication ~
Falls ~ Communication ~ Care planning ~ Documentation ~ Rights
An 87-year-old woman was admitted to hospital with a fractured
femur. That day, she had a total hip replacement. Three weeks
later, she was discharged home into the care of her daughter. Two
days after discharge, the woman suffered a fall at home and was
returned to hospital. Arrangements were made for the woman to have
short-term respite care at a rest home.
The rest home's admission assessment and documentation was
incomplete, and the woman's care plan was not updated during her
stay at the rest home, despite her changing health status. In
addition, the woman had blisters on her heels and a reddening on
her sacrum when she arrived at the rest home. The district health
board's district nursing service was responsible for caring for the
The woman's regular medications included lorazepam, used to
treat anxiety. Three weeks after the woman's admission to the rest
home, her supply of lorazepam ran out on a Friday. The following
day, the woman contacted her daughter in a distressed state. The
daughter telephoned the rest home, but no action was taken to
obtain a repeat prescription until the following Monday.
During her admission, the woman had four falls. The woman's
family was not contacted after the first three falls (the woman
requested that her family not be notified after the first fall
only). When the woman fell for the fourth time, she hit her head on
some drawers, causing a small cut. The GP was contacted and the
woman's daughter was advised.
The next day, a district nurse visited and found the woman's
legs were oedematous and fluid was oozing from them. The woman was
sent to hospital. She was discharged home and referred for
community palliative care. She died a short time later.
It was held that as a result of poor oversight and
communication, the rest home did not ensure that the woman received
the medication she was prescribed. Accordingly, the rest home
failed to provide services with reasonable care and skill, and
breached Right 4(1).
There were lapses in communication between staff and the woman's
family, and there was sub-optimal documentation of the woman's
condition and care. Rest home staff failed to communicate
effectively with one another and with the family to ensure that the
woman received continuity of care, and so breached Right 4(5).
Adverse comment was made about the district health board's
failure to carry out and record a formal risk assessment and carry
out sufficient care planning in relation to pressure ulcer
prevention during the woman's hospital admission.