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Wound management at aged care facility (12HDC01229)
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Aged Care Facility ~ Respite ~ Standard of care ~
Wound care ~ Care planning ~ Assessment and monitoring ~ Rights
4(1), 4(2), 4(5)
A 70-year-old man was admitted to an aged care facility
for 18 days of respite care. The facility specialised in providing
hospital and dementia care. The man had multiple co-morbidities,
including type II diabetes. His left leg had been amputated below
the knee, and his right foot had two chronic infective ulceration
wounds on his big toe and heel. These wounds had been managed in
the community by district nurses for several years. In addition to
the two ulceration wounds, the man had a skin tear on his right
During his stay, the man's right foot wounds deteriorated,
particularly his right big toe, which became necrotic. In addition,
it was suspected that he had a urinary tract infection. The man was
prescribed antibiotics by his general practitioner (GP). Despite
evidence of necrosis, the nursing staff at the facility did not
request that the man's GP review him in person, nor did they inform
his GP of the deterioration of his wounds.
Two days following his discharge from the aged care facility,
the man was admitted to a public hospital, presenting with gangrene
of his right big toe. His right leg was subsequently amputated
above the knee.
It was held that the aged care facility did not provide services
with reasonable care and skill with regard to assessment on
admission, care planning and wound care. There was a lack of
adequate assessment and follow-up of a change in health status. The
aged care facility breached Right 4(1).
The man had a right to have services provided that complied with
legal, professional, ethical, and other standards. The aged care
facility's documentation and communication with the man's family
did not meet the NZ Health and Disability Sector Standards and
breached Right 4(2).
The aged care facility's staff failed to communicate effectively
with one another and with the GP to ensure that the man received
continuity of services. This was a breach of the man's right to
have co-operation among providers and to ensure quality and
continuity of services. Accordingly, the aged care facility
breached Right 4(5).
Adverse comment was made about the aged care facility's use of
wound care products, and about the GP's documentation.
The aged care facility was referred to the Director of
Proceedings. The Director filed a claim at the Human Rights Review
Tribunal which proceeded by agreement. The Human Rights Review
Tribunal made a declaration that the providers had breached Right
4(1) of the Code.