1. On 22 January 2021 HDC received a complaint from Mr A about the care provided to his mother, Mrs B, by Nurse Maude[1] from July 2019 to March 2021. Mrs B was aged 82 years at the time of the events. She lived at home and received in-home support from Nurse Maude until her transition to residential care in March 2021.
   
   
2. Mr A raised concerns that Nurse Maude support workers failed to follow instructions in Mrs B’s care plan[2] regarding the administration of her prescribed eyedrops. He also raised concerns that in various places there were incorrect instructions regarding the administration of Mrs B’s eyedrops, and that staff failed to maintain proper records.
   
   

Information gathered

3. Mrs B had been monitored for glaucoma[3] since 2011 and had a diagnosis of vascular dementia.[4] She needed assistance and supervision to administer her eyedrops and other medication. Support workers were responsible for administering Mrs B’s eyedrops as per the care plan.
   
   
4. Mrs B was prescribed two types of eyedrops. Latanoprost[5] (Teva) was stored in her fridge and administered once a day in the evening, one drop in each eye. Dortimopt[6] was stored in a medication safe and administered twice a day, one drop in each eye (once in the morning with other tablets and once in the evening with the Latanoprost).[7]
   
   
5. The instructions in the care plan for the administration of the eyedrops stated:

‘Daily DHB Eye Drops PM:

“LATANOPROST TEVA — instill[8] one drop into each eye AT NIGHT

Stored in fridge[9]

DORTIMOPT — instill one drop into each eye

Store in safe

Daily DHB Med/Eye-Drops AM:

Remove from lock box

DORTIMOPT eyedrops instill one drop into each eye after instillation.’

6. Nurse Maude stated that the standard practice at the time was for all medication prescriptions for Mrs B to be collected from the pharmacy by family members or delivered to the house by the pharmacy. Nurse Maude also relied on information about prescriptions from Mr A by email and, on at least one occasion, on a Post-it note. Nurse Maude acknowledged that there is no record of any staff member sighting the original prescription for Mrs B’s eyedrop medications.
   
   
7. On 8 January 2021 Mr A took Mrs B to Wellington Hospital for her four-monthly specialist eye appointment. He told HDC that the specialist was concerned that Mrs B’s eye pressure had increased significantly and queried whether the prescribed eyedrops were being administered accurately.
   
   
8. Subsequently Mr A reviewed the progress notes written by the support workers and noticed that some support workers were recording that they were administering two sets of drops in the morning, which was not in line with the prescribing instructions on the Latanoprost packaging, or the care plan. On 13 January 2021 he emailed Mrs B’s case manager at Nurse Maude to request that the correct information be set out clearly in the care plan and that further training be provided to support workers to ensure that the Latanoprost was being administered correctly. He also asked for email confirmation that his request had been actioned so that he could inform the eye specialist that the medications would be administered accurately from that point on.
   
   
9. The case manager confirmed on 13 January 2021 that the information in the care plan was accurate. She also assured Mr A that she would ask the lead support worker to follow up with the other support workers who regularly administered the eyedrops to Mrs B and ensure that everyone was following the care plan.
   
   
10. On 20 January 2021 Mr A emailed the case manager again and said that he had discovered several confusing notes at his mother’s home regarding the administration of her eyedrops. These notes appeared in various documentation — the support worker progress notes,[10] on notes taped onto the medication safe and the front page of the care plan, in Mrs B’s diary, and on the eyedrop bottles (see Appendix A).
    
    
11. Nurse Maude advised HDC that support workers who visited Mrs B had completed their medication competencies, including the administration of eyedrops, and that new support workers would complete the competencies during orientation. While the Medication Management Policy (2018) in place at the time of the incident provided general guidance, it did not include clarification of staff roles, delegation,[11] and transcribing[12] practices. The policy also did not state that medication instructions should be sourced directly from prescribers or pharmacies and did not include information about how support workers should be supervised or assessed.
    
    
12. Nurse Maude acknowledged that the processes it had in place in 2021 meant that Mrs B was not provided with optimal care. Nurse Maude apologised and informed HDC that it is reviewing its medication management policies and processes continuously to ensure that a similar incident does not occur again.
    
    

Independent advice

13. As part of my investigation, I sought independent clinical advice from registered nurse (RN) Ms Barbara Cornor (Appendix B).
    
    
14. RN Cornor acknowledged that all Nurse Maude support workers were well trained in the competencies required for the administration of eyedrops. However, she advised that the support workers consistently failed to follow the instructions provided for medication administration or to document their actions properly, resulting in multiple medication errors. RN Cornor advised that the progress notes[13] were misplaced frequently and, despite concerns raised by Mr A, Nurse Maude failed to implement a consistent system to ensure that the progress notes were secure and accessible.
    
    
15. RN Cornor identified several serious departures from accepted standards in relation to medication management. She advised that there was little evidence to confirm that the medication was administered consistently as prescribed in 2020 and 2021. Specifically, she noted the following:

• • Instructions were recorded inconsistently;
  • Some entries in the progress notes lacked detail, while others failed to specify which drops were given or when;
  • Prescription changes were handled inappropriately;
  • Pharmacy labels were altered; and
  • New instructions were communicated informally, either through Mr A or by text from the coordinator to support workers, who often transcribed these instructions incorrectly in care records.

16. RN Cornor advised that the practices in place during the review period represented significant lapses both clinically and in safe care delivery. They not only breached professional standards but introduced risks to Mrs B’s safety. RN Cornor considered that the delegation of medication responsibilities from the registered nurses to unregulated support workers was managed poorly, with little evidence of supervision or accountability. Nurse Maude updated its Medication Management Policy in 2023 to resolve these issues.
    
    

Decision: Nurse Maude — breach

17. Under Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code), Nurse Maude had a responsibility to provide services to Mrs B with reasonable care and skill. Mrs B relied on Nurse Maude to administer her eyedrops accurately to treat her glaucoma and prevent it from progressing to vision loss. I accept RN Cornor’s advice that several support workers deviated from the instructions in the care plan when administering Mrs B’s eyedrops, and that they failed to document accurate details of the medication they administered. Despite the errors being raised with Nurse Maude on 13 January 2021, the same errors continued for another week until 20 January 2021.
    
    
18. In my view, the failure by several staff both to administer the eyedrops correctly and to document the administration appropriately was in part a result of a lack of clarity in the Medication Management Policy. As noted by RN Cornor, the policy lacked the structure and clarity required to support safe and consistent medication practices. The policy did not define clearly who was allowed to transcribe, at times resulting in transcription being carried out by staff who should not have done so. In addition, the eyedrop medication administration instructions were not sourced directly from the prescriber or pharmacy, as required by the policy. Instead, the instructions came directly from Mr A, which increased the risk of error. While support workers were involved in medication administration, the policy provided limited guidance on how the tasks should be delegated and monitored.
    
    
19. Accordingly, for the reasons outlined above, I find that Nurse Maude breached Right 4(1) of the Code for failing to provide services to Mrs B with reasonable care and skill.
    
    

Changes made since events

20. I acknowledge that since this incident Nurse Maude has strengthened its policies and procedures, including updating its Medication Management Policy in 2023. The updated policy clearly defines the roles and responsibilities of registered nurses, enrolled nurses, and support workers. It states that support workers are strictly limited to administering medications by following prescription instructions provided directly by a prescriber or pharmacy, and that any changes to those instructions must also come from the prescriber or pharmacy. The policy includes clear guidance on transcribing. Care plans have been revised to exclude any direct instructions on medication administration, and instead they direct staff to read and follow the pharmacy-issued labels. The policy also outlines specific training and competency requirements with set times for reassessment. A new chart has been introduced to guide support workers in safe medication administration.
    
    
21. In response to the provisional opinion, Nurse Maude apologised unreservedly to Mrs B and her family, and acknowledged the distress caused. Since 2023 it has also implemented several further improvements, including the following:

• It has adopted the Ministry of Health’s guidelines,[14] which state that all non-pre-packaged medications must be accompanied by a current and accurate medication chart completed by the prescriber.
• It has engaged with the New Zealand Nurses Organisation and the Nursing Council of New Zealand to ensure that its prescribing practices align with the Principles for Quality and Safe Prescribing Practice 2024.
• Case managers must undergo their own medication training, which includes a competency check, as well as complete the medication training provided to support workers, to understand the support workers’ scope of practice. Case managers also complete a module[15] designed to enhance their understanding of direction and delegation in relation to medication support within home and community care settings. Case managers have also developed a letter to send to prescribers to request a current medication chart if one has not been provided already.
• Support workers now use a mobile app to confirm visits, report concerns, and access real-time updates, enhancing coordination of care by providing live data on visit information and enabling timely follow-up by case managers.
• It has upgraded its client record system, giving clinicians access to detailed care plan data, including timestamps and rationale for changes. Visit instructions are now tracked and shared promptly with the scheduling team, while leadership teams can audit all modifications for improved oversight.

22. I am satisfied that the revised policy and the above improvements provide greater clarity and accountability to support a safer and more consistent standard of care in relation to the administration of medication.
    
    

Recommendations and follow-up action

23. Further to the changes made by Nurse Maude, I recommend that Nurse Maude provide a written apology to Mrs B for the failings identified in this report. The apology is to be sent to HDC within three weeks of the date of this report.
    
    
24. I also recommend that Nurse Maude provide evidence of the updated client record management system now in place. This should include how version tracking is used to ensure that staff are working from the most up-to-date care plan. Evidence of this is to be sent to HDC within two months of the date of this report.
    
    
25. An anonymised copy of this report (naming only the advisor and Nurse Maude) will be sent to HealthCERT and Health New Zealand (Wellington and Hutt Valley District) and placed on the HDC website (www.hdc.org.nz) for educational purposes.

Carolyn Cooper

Aged Care Commissioner