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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
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
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
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.
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
- "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
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.
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:
- 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.
- 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.
- There should be ongoing training for support workers,
especially in areas such as mobilising, lifting, risk assessments
and management, and manual handling.
- 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
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