This case concerns the provision of care to consumers with multiple comorbidities who are at risk of rapid and significant deterioration, which is the current day-to-day reality of aged residential care. Consumers are reliant on the service provider’s quality control system working as intended, and, in this case, it failed the woman through staff not following correct protocol and process. While the Deputy Commissioner did not find the provider in breach of the Code, she felt it important to comment on its quality system publicly. The Deputy Commissioner said that the implementation of a quality control/improvement system is effective only if it is applied correctly.
The woman had a complex medical history and was admitted to the rest home in 2015 for rest-home-level care as a result of worsening back pain and decreased mobility. She had a history of pressure injuries, and in 2019 one pressure injury deteriorated and became unstageable and required hospital treatment.
The Deputy Commissioner considered that there were a number of areas for improvement for the rest home. She was critical that pressure injuries were not recorded in the incident management system and not recorded on separate forms, two-hourly repositioning of the woman was under recorded, and there were earlier opportunities to refer the woman to the wound nurse specialist or GP and to communicate to the woman’s family the extent and management of the pressure injuries.
The Deputy Commissioner recommended that the rest home ensure that HealthCERT is notified of unstageable pressure injuries in a timely way (and provide an audit of previous notifications); ; use an anonymised version of her report as a case study; and provide a written apology to the woman’s family.