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Care provided to elderly woman (11HDC00883)

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(11HDC00883, 11 June 2014)

Aged care facility ~ Facility manager ~ Nurse manager ~ Registered nurse ~ Standard of care ~ Assessment and monitoring ~ Care planning ~ Documentation ~ Communication ~ Dignity ~ Rights 3, 4(1), 4(2), 4(5) 

An 86-year-old woman was admitted to a rest home following an admission to hospital for treatment of a scalp laceration following a fall.

On admission, a care plan and nursing assessment were completed. The care plan did not record how to manage the woman's diabetes, dietary needs, prolapses, dementia and swallowing difficulties. The woman's care plan was not kept updated.

During her admission, the woman had a number of changes to her condition, including a suspected mini stroke, a number of falls, swallowing difficulties and rapid weight loss. The woman's changing condition was not adequately monitored, assessed, managed or documented by the rest home's staff, and her personal care and hygiene were not maintained to an acceptable standard. The rest home's staff also failed, on occasion, to complete incident forms or follow up incidents adequately.

The woman was transferred to a different rest home at the request of her daughters. A few days after her transfer, the woman was admitted to a public hospital. Investigations at the public hospital indicated that the woman was hypothermic, and had urosepsis and acute renal failure secondary to infection. She died a short time later.

The nurse manager breached Right 4(1) for providing suboptimal care to the woman with regard to care planning, incident reporting, and her monitoring, assessment, documentation and management of the woman's changing condition. The nurse manager also breached Right 4(2) for failing to comply with professional standards regarding documentation, and Right 3 for leaving the woman for an unreasonable length of time soiled or wet from urine, which showed a lack of respect for her dignity. The nurse manager was referred to the Director of Proceedings.

The facility manager had overall responsibility for ensuring a quality service was provided to the woman. The facility manager did not provide care to the woman with reasonable care and skill by failing to ensure that the rest home's staff completed incident forms and followed up incidents adequately. The facility manager also did not ensure that the woman's care plans were completed adequately and remained updated when her condition changed, and did not ensure that the woman's clinical record and documentation were kept up to date. For these reasons, the facility manager breached Right 4(1).

The rest home breached Right 4(1) because it failed in its responsibility to ensure that staff complied with policies and provided services of an appropriate standard to the woman. The rest home also breached Right 4(2) because its documentation was suboptimal. The rest home also breached Right 4(5) for failing to ensure that its staff communicated effectively with one another and with other health professionals to ensure that the woman received quality and continuity of services. 

The Director of Proceedings decided not to institute proceedings in this case.

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