The Commissioner received a complaint about treatment the complainant's mother received at a rest home. The complaint is that:
- The consumer's care was neglected while she was a resident at the rest home.
- When the consumer's condition deteriorated, the rest home did not call a doctor soon enough. This resulted in the consumer's admission to hospital in mid-May 1997. The complainant feels if a doctor had come when she asked, her mother would not have been admitted to hospital.
- Since the rest home changed hands, staff have not had the necessary time to devote to residents. On one occasion the complainant wanted to ask for help for her but she could not find a member of staff to help.
- Her mother was in a unit with another sick lady and was left to struggle on alone.
- The complainant asked the rest home manager three times for a doctor to visit her mother and the doctor came three days later. The doctor informed the complainant that he had not been asked to come earlier.
- The complainant said her mother was so ill that she would try to go to the toilet, would fall on the floor and would have to wait for the other resident to find her and ring the bell. It took two weeks until someone noticed a lump and bruising on the consumer's leg from a fall. The lump and bruising was not noted.
- On one occasion, at 2.45pm the complainant got a call from the other elderly resident in her mother's unit to come to their unit. When she got there she found the consumer in a summer nightdress, cold and lying in an armchair. The complainant said she sat there from 3.00pm until 4.45pm before anyone came to the unit. When the complainant left at 5.30pm a nurse had not checked on either the consumer or the other elderly resident.
The complaint was received on 28 May 1997 and an investigation was undertaken. Information was obtained from:
- The Complainant
- The Consumer
- The Rest Home Manager
- The Rest Home Licensee
Relevant clinical records and resident notes and relevant documentation were requested and viewed.
Outcome of Investigation
The complainant said her 89-year-old mother had resided at the rest home since August 1995. The complainant said when her mother first went to the rest home she was assessed as a SNAL level 2. The rest home changed ownership in approximately March/April 1997 and is now known by a different name. The consumer shared unit five with another lady. The complainant said she fed her mother each night.
In her letter of complaint to the rest home dated mid-May 1997, the complainant stated her mother and her room mate had been sick for a week and both were left to struggle on alone. The complainant also said her mother was so ill that she would fall on the floor when she tried to go to the toilet and on three occasions the complainant asked the rest home manager to contact a doctor. According to the manager, she had explained to the complainant that on Sunday the doctor had forgotten to visit, on Monday he failed to answer her call and finally he visited the consumer on Tuesday night. The complainant said that when she telephoned the doctor and requested that he come and visit her mother, he informed her that he had not been requested to see the consumer.
In his letter of response to the Commissioner dated 9 November 1998, the doctor stated he could not recollect when he was contacted by the rest home and made aware of the consumer's condition prior to her hospital admission. However, he noted in this letter:
"I should say that I had concerns at that time about the communication that I was receiving from the head nurse at that time relating to clinical information that I should have been receiving. I subsequently spoke at length to the rest home owner about my concerns, and following discussions with this person she subsequently resigned."
In the complainant's letter of mid-May, she noted that on one occasion she found her mother in a summer nightdress lying in an armchair. She put her mother into a dressing gown and sat from 3.00pm until 4.45pm before someone came to the unit. The complainant stated no nurse had visited before 5.30pm when she left. The complainant also noted that after the consumer had been a week in a unit where residents tended to be more independent, the rest home manager rang the complainant to see if she could shift the consumer into the main building. The complainant said she was relieved but wondered why it had taken so long as her mother needed constant care.
The rest home manager's response
In the manager's response to the Commissioner of 2 July 1997, she stated:
"This was not the first time that [the consumer] had been ill, she was a 90 year old lady with chronic bronchitis which led to frequent bouts of pneumonia.After investigation it was found that [the complainant] wanted her mother in a unit, where most of the residents are reasonably independent.""It was obvious after being here a month that [the consumer] was not suited to the units. I therefore tried to make arrangements to move her to the Mainblock, where the carers could give her more individual attention and also so that she would be closer to my office. This took me a while (two weeks), since at that time there was no vacancy, I had to arrange for another resident to move out temporarily until [the consumer] was well enough to move back to the units."
In this response, the manager also stated:
"The complainant's letter seems contradicting at times i.e. that she was called out to her mother ?sat from 3.00pm to 4.45pm, before anyone came - gave her mother 'tea' and stayed until 5.30pm, but no nurse had come. who gave her the tea? This comes on a tray from the kitchen, who gave them their medication?, this is given at 5pm by the caregiver.
The staff would not have intervened or bothered the ladies while they were having visitors, only for essential cares."
In relation to the doctor's knowledge of the consumer's condition, the rest home manager noted:
"As far as not notifying [the doctor] of her condition; he was fully aware of her [the consumer's] condition, she had had two doses of different antibiotics and was on the second, when she [the complainant] removed her mother from the rest home?[the doctor] was asked to come and see her mother, since he was going on holiday, he said he would come on the Sunday, he never came, I phoned his rooms and the receptionist said she would give him the message, this was apparently not done. I phoned him on Tuesday and asked why he never came, he said he forgot to diarise it, but would come that evening."
The rest home manager also noted:
"The staff were generally new, so obviously did not know the residents and relatives as well as the old staff did. When new staff take over the atmosphere changes, as every management brings their own ideas and ways. The staff ratio has never changed, there were exactly the same amount of staff then as there was with the old management, I believe it is clear that [the consumer] was well cared for while at [the rest home], and indeed received a lot of time by the caregivers, in meeting her needs."
In a letter of July 1997 to the complainant, the rest home manager stated:
"In my capacity as a registered nurse, with a bachelor of nursing degree and 28 years nursing experience, I did not find that her condition had deteriorated to such an extent that she needed emergency hospital care, however, I never underestimated that she was a sick person. Her condition remained the same during the period she was on antibiotics."
In this letter the manager also stated:
"I fail to see that your mother was neglected. We are not a hospital, and only a second stage rest home, we do not have the facility available to be a hospital, nor do we have the qualified experienced staff they have. We employ caregivers who take care of the residents' daily needs, i.e. (washing, eating, cleaning, etc)."
The resident notes record the following:
[...] April 1997: "AM: Doctor notified re [consumer's] condition. NIGHT: Found by [consumer's room mate] lying on the floor. Must have fallen out of bed, appears short of breath on examination. Check frequently at night."
[Next day] April 1997: "AM: Fell over after shower/no injuries noted. Rested in bed all day. PM: Seen by doctor. To commence on Rulide 150mg 1 BD?90 notifies doctor. Daughter notified."
[ ... ] May 1997: night, "[Consumer's room mate] rang the bell at 2400, found her on the floor. She was massaging her legs took to toilet later settled and found asleep on the other two rounds."
[Next day] May 1997: "PM:?Assisted by [daughter] with meals has bruises left legs and vaginal area. Could be fall?"
[Four days later] May 1997: "PM: daughter came about 4.30pm to visit and she put her to bed. Before she went home requested to feed Mum at tea times."
[Next day] May 1997: "PM: has a chesty loose cough and appears SOB. Doctor notified.
[Next day] May 1997: "PM: Seen by [doctor] to commence on Augmentin 500mg. TBD. 8/7. Still has Bronchial infection. No signs of asthma?if bronchial infection won't improve in 5 days to chest x-ray."
[Three days later] May 1997: "AM: Bruising on leg much the same?had a fall this morning. No bruising or tears."
[Two days later] May 1997: "PM: Admitted to [...] hospital. Daughter came in to visit. Unhappy with mother's state. She called [doctor]."
[Next day] May 1997: "[Daughter] came to see me (nurse manager) to lodge a complaint about treatment given to her mother. [Doctor] came in, [the licensee] and myself discussed [the consumer's] condition with him. [The doctor] responded that he had quite a difficult time to get [the consumer] admitted since she was not an "emergency" case. He was well aware of her condition and had planned to send her for an x-ray today if she had not improved. I did enlighten [the complainant] that her other was well cared for at all times. [The doctor] was well aware of her condition at all times. She insisted on an investigation which I will duly do."
The consumer was admitted to hospital in mid-May 1997 and discharged in mid-July 1997. The discharge summary records the consumer was alert and not distressed on admission. The consumer's initial assessment by the hospital was undertaken three days after admission. The medical diagnosis stated the consumer "appears unsteady on her feet" and "will require assistance with washing/showering." The hospital summary to the doctor on the day of discharge records:
"[The consumer] was admitted with a two week deterioration including a productive cough, increasing shortness of breath, poor appetite and confusion. She had previously been treated with one week of Rulide and five days of Augmentin with no improvement. Intravenous fluids and Augmentin were commenced. She improved over the following days but continued to be confused."
In the transfer of patient form dated two days before discharge, the nursing assessment of the consumer states:
"admitted with extensive bruising - skin tears and a history of frequent falls?a delightful little lady - complaint when co-operative but can become extremely confused/aggressive."
The transfer form also notes:
"problems all related to dementia and wandering which puts her at risk of falls".
It was noted that the consumer had one minor fall during her hospital stay but sustained no injury. This fall occurred four days after admission at 11 o'clock. Under the heading 'dementia' it is recorded that:
"Mini mental State Exam 15/30. Although most often a delightful woman, [the consumer] does get agitated especially towards the end of the day. She can occasionally get disruptive and aggressive and has in the past required small doses of Haloperidol."
The hospital summary notes:
"[The consumer] is discharged to [a] private hospital under your care. Her congestive cardiac failure is improving and she is clinically quite well. Due to dementia and a tendency towards wandering, [the consumer] requires a safe environment."
The Code of Health and Disability Services Consumers' Rights
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
3) Every consumer has the right to have services provided in a manner consistent with his or her needs.
Opinion: Breach - Rest Home
In my opinion, the rest home breached Right 4(2) and Right 4(3) of the Code of Health and Disability Services Consumers' Rights as follows:
While the rest home does not have the resources of a hospital and therefore cannot provide the medical services that a hospital provides, the rest home failed to demonstrate that it provided the basic services of a second stage rest home. These services include ensuring residents have constant supervision and their basic needs are met.
In my opinion the consumer's physical needs were not always met. Examples include the three days it took for the consumer to see a doctor, insufficient supervision by the rest home staff such as the occasion the consumer sat unattended for approximately two and a half hours and the occasion when the complainant found the consumer in a summer nightdress, cold and lying in an armchair and the time taken to notice the lump and bruising on the consumer's leg after a fall.
I note that it took two weeks to move the consumer back to the main block where carers could give her more individual attention. This only occurred as there were no vacancies and was not a breach of the Code.
I recommend that the rest home takes the following actions:
- Provides a written apology to both the consumer and the complainant. This apology should be sent to the Commissioner who will forward it to them.
- Familiarises all staff with their obligations under the Code of Health and Disability Services Consumers' Rights.
- Reviews its assessments of residents' needs and ensure that each resident is receiving the level of care appropriate to their situation.
- Reassesses the lines of communication between the rest home and the doctor in charge of the rest home residents to ensure effective communication.
For further information, contact: HDC Communications Section (09) 373 1060.