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Response to deteriorating skin condition (14HDC01005)

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(14HDC01005, 20 June 2016)

Rest home ~ Registered nurse ~ Hospital-level care ~ Pain relief ~ Wound care ~ Documentation ~ Mycosis fungoides ~ Right 4(1) 

A 77-year-old woman had the skin condition, mycosis fungoides, which is a type of lymphoma that begins as scaly, itchy, patches on the skin, followed by thicker plaques and eventually tumours. The woman also had lung cancer. The woman required hospital-level rest home care, and took up residence at a rest home.

The woman's skin condition began to deteriorate and staff noticed blood on her bed linen and sheets and she reported experiencing pain during personal cares. The woman was prescribed codeine for pain relief on an as needed (PRN) basis. She required this pain relief in addition to her regular paracetamol. The woman had a pain care plan but it was not updated in response to her changing condition.

A few days later, the woman telephoned her daughter, who said her mother reported that she was in a lot of pain. The clinical manager spoke to the daughter and commenced the woman on an hourly pain assessment tool. The clinical manager sent a facsimile to the woman's general practitioner (GP) regarding the woman's pain levels. That afternoon, a nurse from the GP's medical centre responded with an amended pain management plan to give paracetamol four times daily, and codeine every four hours prior to cares. The hourly pain assessment tool was filled in by staff approximately hourly between 3 and 8pm, but was not filled in hourly after that.

The following day, a registered nurse contacted the GP again with concerns about the woman's skin condition and pain levels. The GP reviewed the woman and liaised with the public hospital for the woman to be admitted that day. The woman was given palliative care in hospital, where she sadly died a few days later.

It was held that that the woman's skin condition was deteriorating from when she was experiencing pain during her cares and blood on her bed linen. Her pain experience was changing, as she required more PRN codeine and began requesting pain relief for "pain all over". However, staff failed to contact the GP about either aspect of the woman's changing condition until a few days later. In addition, staff also failed to update the woman's pain care plan and document the effectiveness of administered pain relief appropriately. Accordingly, the rest home did not provide services to the woman with reasonable care and skill, and breached Right 4(1).

Adverse comment was made that the clinical manager should have been more alert to the woman's increased need for PRN codeine.

It was recommended that the rest home arrange for further staff training regarding pain management and pain assessment, and apologise to the woman's family. 

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