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Home support for a high needs client (10HDC00547)

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A Report by the Deputy Health and Disability Commissioner

(10HDC00547, 18 January 2012)

This case study summarises the Deputy Commissioner's consideration of a case involving care provided by a home care provider and a support worker to an elderly woman who, sadly, died following a fall at home. This summary concludes by outlining learning opportunities associated with the case.

A 94-year-old woman was admitted to a public hospital after deteriorating following a fall at a rest home. She had a history of falls. A CT scan showed that she had had a subarachnoid haemorrhage.

Hospital Assessment
A few days later, the woman was assessed by a geriatrician who noted that she was unsafe to mobilise without assistance but that this may improve over time. Two days later, the hospital developed a Care Plan Report for her. She was assessed as requiring 24-hour supervision with tasks. The report stated that she was "currently mobile with a frame with supervision" and was a high falls risk.

The woman was assessed as needing hospital-level care. Her family decided to care for her at home, as her daughter-in-law had previous experience caring for relatives.

The hospital's Care Plan Report (including the geriatrician's assessment) was faxed to the local home care provider. This provider was contracted to provide 14 hours of personal care per week (two hours a day, seven days a week). Another home care provider provided support for the woman at other times.

Home Care Provider Assessment
The home care provider's co-ordinator (who is not a registered nurse), assessed the elderly woman and, with the woman's daughter-in-law, wrote up a Basic Needs Service Plan. The woman's high falls risk was noted under "mobility/manual handling". She was noted as being "Dependent on walking frame to weight-bear" and "tires easily". Under intervention it was noted "Mobilises slowly with aid of walking frame" and "assistance required when transferring from sitting to standing with frame". Under "risks" her high falls risk was again noted.

The co-ordinator also completed a Hazard Identification (Area) Checklist. Under "employee's awareness of client capabilities" was written "High falls risk, limited mobility, hearing impairment, some dementia evident: Remain aware & assist as per Service Plan".

Two support workers were assigned to provide care for the woman. The co-ordinator recalls instructing the support workers that the woman was a high falls risk, had limited mobility, and was dependent on her walking frame.

The support worker
One of the support workers had been employed for nearly three years. She had undergone orientation training and attended 10 training sessions, including back care, personal care and hoist use. She had previously worked for another home care provider for approximately a year. The support worker had no formal qualifications in home care. She cannot recall whether the co-ordinator told her about the elderly woman's fall risk or whether she saw her care plan, but does recall being told that she had had a previous fall.

The support worker was providing support services to the elderly woman when the woman fell and was injured. Conflicting accounts were provided to HDC as to the circumstances of the incident in which she fell. In summary, the woman was taken to the toilet by the support worker and on the way back, was left standing with her walker while the support worker stepped away momentarily. The support worker said she heard the walker move but was unable to prevent her from falling backwards and hitting her head on a piece of furniture. An ambulance was called and the woman was transferred to the local hospital where she died.

Further action
The provider undertook an internal investigation into the incident and shared its findings with the Coroner. The investigation found that the care plan had not documented that she needed to be assisted at all times when mobilising. The investigation recommended:

  • "All support workers to receive guidance on the importance of safe mobilising of clients at risk of falling.
  • The case to be discussed with support workers as a learning tool."

The provider noted that "[s]pecific training for support workers on mobilising clients is not provided, as this is deemed part of the general training and support provided" but conceded that such training "may have prevented this incident". Since the incident, the support worker received further training and said that she is now more careful when assisting people to move around.

Learning opportunities
HDC obtained preliminary expert advice from Tanya Bish, a registered nurse with 20 years of gerontological nursing and management experience predominately in aged residential care. Ms Bish advised that the care was generally reasonable but there were areas that could be strengthened in order to improve the quality of service provided to other clients, namely:

  1. If a consumer requires assistance with mobility it should be clearly documented as 'assist' in a care plan so as not to be confused with supervision.
  2. Where possible, registered nurses should assess and prepare care plans for appropriate clients (eg, those assessed as needing hospital-level care) and continue to have oversight of them.
  3. There should be ongoing training for support workers, especially in areas such as mobilising, lifting, risk assessments and management, and manual handling.
  4. There should be a process in place to ensure that support workers read and understand their clients' care plans.

The elderly woman's son also suggested that family members be provided education and training to care for people in their own homes.

As the expert advised that the care was generally reasonable and the provider had taken appropriate steps to improve its services, no further action was taken on the complaint.

A copy of this anonymised case study will be sent to Health Workforce New Zealand for consideration when formulating policies on the aged care workforce, and placed on the HDC website for educational purposes.

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