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Failure to report rest home resident’s fall (05HDC16647)
Download Failure to report rest home resident’s fall (05HDC16647) (PDF 174Kb)
(05HDC16647, 31 May 2006)
Rest home ~ Caregiver ~ Elder care ~ Dementia ~ Care plan ~
Fall ~ Fracture ~ Incident reporting ~ Rights 4(1), 4(3), 4(4),
A woman complained about the care provided to her mother by a
rest home. The elderly woman required full care, could not
communicate with staff, and did not mobilise at all. While
transferring the woman from chair to bed, a caregiver "dropped"
her, which resulted in a broken arm and facial bruising. The
caregiver did not report the fall, and failed to complete an
accurate incident form.
Two days later, bruising and misalignment of the woman's arm was
noted, and subsequent investigation showed the fracture. The owner
of the home immediately started an investigation, as it was not
known how the injury had been caused. Only after a number of staff
meetings and individual interviews did the caregiver admit, nearly
three weeks later, to being involved in the incident resulting in
the injury. The caregiver was subsequently dismissed, having
refused to attend the disciplinary process.
It is unacceptable for a caregiver to drop a patient when moving
her, particularly when attempting to do so without a second staff
member to help as required by a care plan. In these circumstances,
the caregiver failed to exercise reasonable care and skill and
breached Right 4(1).
The caregiver's failure to report the fall also resulted in
delays in informing the woman's family that their mother had
suffered an injury. The woman suffered from dementia and was
unable to communicate. In these circumstances, the caregiver had a
duty to provide information to the family, including an explanation
of the woman's condition.
It was held that the caregiver acted in a dishonest manner by
failing to report an incident, consciously and repeatedly deceiving
during an investigation process, and making false claims about her
lifting training. She also made an unsubstantiated statement that
she had admitted her involvement in the accident under duress. By
her actions, the caregiver breached Rights 4(1), 4(3) and 4(4).
The caregiver was referred to the Director of Proceedings, who
issued proceedings before the Human Rights Review Tribunal. The
Tribunal found that the caregiver breached Right 4(1) in that she
failed to comply with the "two person lift" policy of the rest home
and failed to transfer the woman safely from her chair to her bed.
It also found that she breached Right 4(2) by failing to complete
an adequate Incident Report when the woman fell during the transfer
from her chair to the bed. The caregiver also breached Right 4(5)
in that she failed to notify anyone that the woman had fallen while
in her care.
In a subsequent decision on damages, the Tribunal awarded the
woman's daughter $3,500 for injury to feelings. However, this
decision was subject to the Court of Appeal decision in Marks v
The Director of Proceedings  NZCA 151, which concerned
the definition of "aggrieved person" under the Act. As a result of
the Court of Appeal's decision in Marks, the award of
damages was not enforceable because the woman's daughter was not a
consumer of health services in this case. The Tribunal's
declarations in relation to breaches of the Code stand.
Link to Human Rights Review Tribunal decision: