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Inadequate care of elderly rest home resident (12HDC00571)
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Rest home ~ Nurse manager ~ Registered nurse ~ dementia ~
care planning ~ Falls ~ Wound care ~ Handover ~ Assessment ~ Hip
fracture ~ Rights 4(1), 4(2), 4(5)
An elderly woman who was a long-term resident at the rest home,
had osteoporosis, some cognitive impairment, and a progressive
dementia. The woman was experiencing low back pain and was
receiving ongoing opiate pain relief. She required full assistance
for personal cares, and walked with a mobility frame.
When a reddened area on the woman's back was identified, the
Nurse Manager (NM) considered that the redness was pressure
related. No short-term care plan was instigated that day or a few
days later when a urinary tract infection was suspected.
A short time later the registered nurse (RN) on weekend duty
reviewed the woman. The woman was transferred to hospital because
of her increased back pain. The hospital assessment resulted in a
prescription for continued opiates and three days of diazepam. The
RN transcribed the hospital prescriptions onto medication
administration charts. The RN applied a Duoderm dressing to the
wound but did not start a short-term care plan, record the size of
the wound, or describe the grade of the wound.
The woman had two falls within a few days. The NM completed an
incident form after the first fall, and follow-up was scheduled for
when a general practitioner was due to visit. After the second
fall, the NM examined the woman and instigated short-term and pain
management care plans, but documented few instructions for staff to
follow. The GP reviewed the woman, but the NM did not advise the GP
of the woman's falls.
Handover of residents' care and communication with care staff
usually took place via a staff communication book, resident
progress notes, and a handover sheet. The NM and the weekend RN did
not usually see each other in person. Handover between the NM and
RN roles was not formalised or governed by a facility policy.
Communication between NM and the weekend RN was usually performed
by use of an RN communication book. The NM did not communicate to
the RN in the RN communication book or in person that the woman had
The NM went on leave for 10 days. The RN did not review or
familiarise herself with the woman's incident reports or handover
sheets prior to providing nurse manager cover. During the NM's
leave, the RN reviewed the woman. The RN noted that the woman had
new bruising and her left leg was "dragging" but the RN could not
identify a cause. The RN did not consider a fracture as the cause
of the woman's pain. The RN did not seek advice from the GP or the
hospital, and did not advise the family of the woman's
A visiting physiotherapist assessed the woman and observed that
the woman's left leg was laterally rotated and shortened, and
considered that the woman had a recent hip fracture. The woman was
transferred to hospital by ambulance. A fracture of the neck of
femur was diagnosed. The hospital noted and treated the pressure
area wound on the woman's back.
The NM did not utilise short-term care plans for pressure
management of the woman's back or suspected urinary tract
infection. No pain chart was used in conjunction with the Pain
Management Plan formulated after the woman's second fall. Limited
guidance was given to staff regarding the woman's reduced mobility,
why her urine should be checked, and management of the woman's
constipation. Appropriately skilled assessments of treatment
efficacy were not consistently carried out. The NM did not provide
services with reasonable care and skill and, accordingly, breached
Right 4(1) of the Code of Health and Disability Services Consumers'
It was found that the NM did not advise the GP about the woman's
falls. In addition, the informal and indirect nature of handover
communications between the NM and the RN, in tandem with infrequent
use of short-term care plans, meant that important clinical
information was not adequately provided to the registered nurse.
This contributed to a lack of continuity in care and the NM
breached Right 4(5).
The RN failed to review and appropriately familiarise herself
with the woman's clinical situation. The RN's assessment,
evaluation and response to the woman's bruising and dragging of her
leg were not adequate. The RN failed to provide services to the
woman with reasonable care and skill and, therefore, breached Right
4(1). The RN did not complete an accurate wound description, wound
chart and short-term wound care plan. These actions did not comply
with professional standards and, accordingly, the RN breached Right
The owner/operator of the facility did not take sufficient steps
to ensure that appropriate systems, policies and guidelines were in
place to provide services to the woman with reasonable care and
skill. Therefore, it breached Right 4(1).