Investigation: resident of community living home suffers burns

A woman living with spastic quadriplegia, who does not communicate verbally, was a resident at an assisted living facility.

There were several oversights in the management of her continence products, including a delay in monitoring and replacing them for 12 hours. It was discovered that the continence product had leaked, and that she had sustained burns to both thighs.

There was also a lack of frequent pain assessments, inadequate medication administration, inconsistent documentation, a failure to seek timely medical review, and insufficient communication with the woman’s welfare guardian.


Deputy Commissioner Rose Wall found that the facility did not provide services with reasonable care and skill, and in a manner that respected the woman’s dignity.

The Deputy Commissioner also found that the Community Homes Manager — an enrolled nurse — failed to seek clinical advice from a registered nurse, and provided insufficient guidance to staff when the burns were reported to her.

Ms Wall noted: “My report highlights the importance of service providers having robust policies and procedures in place to support staff in caring for particularly vulnerable residents.”


It was recommended that the service provider give evidence that earlier recommendations set out in the internal investigation have been implemented, and consider implementing a handover tool to ensure that accurate information is communicated among staff.

The provider was also asked to undertake a number of audits in relation to its medication administration records and continence product supplies, as well as to review its process in place for sourcing medical care.

Both the provider and the enrolled nurse involved were asked to provide a written apology to the woman, and the Nursing Council of New Zealand was asked to consider whether the enrolled nurse’s competence should be reviewed. The full report on case 19HDC01464 is available here.