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Wound care, documentation and consultation with family (09HDC01035)
Download Wound care, documentation and consultation with family (09HDC01035) (PDF 140Kb)
(09HDC01035, 29 June 2010)
Rest home ~ Registered nurse ~ District health board ~
Dementia ~ Assessment ~ Monitoring ~ Wound management ~ Pressure
sores ~ Documentation ~ Care plan ~ Consultation with family ~
Standard of care ~ Rights 4(1), 4(2)
A woman complained about the care provided to her elderly mother
while she was a resident at a rest home. After she was assessed for
hospital level care and transferred to a private hospital, the
private hospital found pressure sores on her heels and a rash in
The woman was initially admitted for short periods of respite
care for a year and then became a permanent resident of the rest
home. A year later she was assessed for dementia care and
transferred to the dementia unit within the rest home.
Approximately two years later, her health deteriorated and she was
assessed as requiring hospital level care by a visiting
psychogeriatric nurse practitioner.
Two nurses, one working as a registered nurse and the other as
nurse manager, who had been working at the rest home over the
preceding six months, failed to review the woman's care plan and
appropriately document their assessments of her general health and
develop a wound care plan for her recurring groin rash. The
communication book for the dementia unit for the period under
investigation went missing. No one at the rest home consulted with
the woman's family about her care, despite this being a requirement
of the rest home's contract with the district health board.
It was held that the registered nurse lacked insight into the
level of care required, did not fulfil her responsibilities to
manage and provide the care appropriately, and did not adequately
consult with the woman's family, in breach of Rights 4(1) and 4(2).
The nurse manager did not provide sufficient oversight and guidance
to her staff on the care the woman needed, consult adequately with
the woman's family, or respond appropriately to the woman's
deterioration, in breach of Rights 4(1) and 4(2). The rest home
failed to provide care to the woman with reasonable care and skill,
which complied with all the relevant standards and contractual
obligations, including review of her care plan, communication with
her family, and the need for timely reassessment by Needs
Assessment and Service Co-ordination Services, in breach of Rights
4(1) and 4(2).
This case highlights the importance of rest homes having
adequate systems in place to ensure that dementia patients receive
appropriate care. It also highlights the importance of
communicating with family members and involving them in the care of
their loved ones.