Page Section: Centre Content Column
Response to deteriorating rest home resident (12HDC01091)
Download Response to deteriorating rest home resident (12HDC01091) (PDF 72Kb)
Rest home ~ Registered nurse ~ Nursing care ~ Aspiration ~
Documentation ~ Communication ~ Right 4(1)
An 86-year-old man was admitted to a rest home after being
assessed as requiring 24-hour hospital-level care. A registered
nurse (RN) completed the man's admission assessments and initial
care plan, and noted that he was diabetic and required mildly
thickened fluids to prevent aspiration pneumonia.
Five days after his admission, following the man's evening meal,
a healthcare assistant (HCA) noted that the man was finding it hard
to communicate and breathe. The HCA reported the man's condition to
the RN, who immediately assessed the man and noted that his
breathing was "chesty and gurgly". The RN considered that the man
was experiencing his "usual respiratory distress" and commenced him
on oxygen at a rate of three litres per minute. He advised that the
man's condition improved on oxygen, but did not record that in the
At approximately 11pm that evening, the RN handed over the man's
care to a second RN. The second RN assessed the man as not
warranting hospital admission or medical intervention. At 2.30am
the following morning, the man complained of not being able to
breathe, and the RN increased the man's oxygen to four litres per
minute without checking whether oxygen therapy had been prescribed.
She did not record the man's response to the oxygen. At 7:45am the
same day, the RN recorded that the man remained "dyspnoeic and
gurgly", and he was transferred to hospital.
It was held that while the first RN's initial assessments and
care plan for the man were appropriate, he failed to respond
appropriately to signs and symptoms of the man's deteriorating
health, and to escalate his concerns to the man's general
practitioner (GP) or refer him to hospital. Accordingly, he
breached Right 4(1).
It was held that the second RN also failed to respond
appropriately to the man's signs and symptoms, by failing to
escalate her concerns to the man's GP for advice, or refer him to
hospital. Accordingly, she breached Right 4(1).
The company which owned and operated the rest home was held to
have breached Right 4(1) for failing to have appropriate senior
staffing in place, failing to provide sufficient clarity in its
Incident Report Policy on the types of events that should be
reported, and for failing to ensure its staff met the required
standards for documentation.
Adverse comment was also made about the company's communication
with the man's wife regarding his deteriorating health.