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Care provided to frail, elderly woman (11HDC00512)
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(11HDC00512, 16 April
Aged care provider ~ Weight loss ~ Nutrition and hydration ~
Care planning ~ Assessment and monitoring ~ Right 4(1)
A 95-year-old woman was admitted to a residential care facility
(private hospital). The woman had a history of swallowing
difficulties and weight loss, and she required a puréed diet. A
month after admission, the woman's weight was recorded at
Nursing assessments were completed at the time of the woman's
admission. However, no initial short-term care plan was completed,
and her long-term care plan was not completed until seven months
after her admission.
For the first six months of her admission, the woman appeared to
be eating and drinking reasonably well and her weight increased
slightly. Nine months after her admission, it was noted that the
woman might be dehydrated, and a fluid balance chart was commenced.
She had started losing weight. A few weeks later, the general
practitioner (GP) noted that the woman was very underweight and
recommended that she have a nutritional supplement. The woman
started on the nutritional supplement Complan, but she continued to
Just over a year after her admission, the woman weighed 35.55kg.
This was a loss of 10.8% over the previous six months. Although
staff often observed that the woman was reluctant to eat, little
was done to investigate or address her ongoing weight loss. The
woman's care plan was updated. It was noted that the woman had been
refusing to eat and that she appeared to prefer the assistance of
particular staff. However, the care plan did not refer to the
woman's puréed diet, the Complan, the fluid balance chart, or her
ongoing weight loss.
Weight checks the following month indicated that the woman was
continuing to lose weight. The woman was due to be seen for her
monthly GP review but as the GP did not have time to see all of the
patients he was scheduled to that day, the woman's review was
postponed until the GP's next scheduled visit.
Before this could occur, the woman's condition deteriorated and
she was admitted to a public hospital. She was diagnosed with, and
treated for, community acquired pneumonia with secondary aspiration
pneumonia and silent aspiration. A month later she was discharged
to another private hospital. She died a short time
There were deficiencies in the care provided to the woman by the
residential care facility, particularly in relation to care
planning, weight management and the response to her weight loss,
and the assessment and monitoring of her nutrition and
In these circumstances, it was held that there was a lack of
reasonable care and skill in the services provided, and accordingly
the residential care facility breached Right 4(1).