Appendix A: In-house clinical advice to Commissioner

The following in-house advice was obtained from Dr Isabella Wright:

‘CLINICAL ADVICE — AGED CARE

CONSUMER         :            [Mr A]

PROVIDER            :            Eldon Lodge Rest Home, Oceania Group

FILE NUMBER      :           C21HDC03028

 

1. Thank you for the request that I provide clinical advice in relation to the complaint about the care provided by Eldon Lodge Rest Home. In preparing the advice on this case, to the best of my knowledge I have no personal or professional conflict of interest. I agree to follow the Commissioner’s Guidelines for Independent Advisors.

 

2. Documents reviewed

• • Consumer complaint submitted by Mr [A]’s daughter
  • Eldon Lodge complaint response with supporting organisational policies
  • Clinical documentation relating to Mr [A] including nursing assessments, nursing care plan, nursing and medical notes, medication records, weight monitoring forms and record of communication with EPOA
  • An external certification audit report completed May 2021
  • Additional clinical documentation provided on 9/2/2023

3. Complaint

Mr [A]’s daughter and EPOA, Mrs [B], has expressed concern about the care her father received from Eldon Lodge Rest Home prior to his death [in early] August 2021. Mrs [B] is concerned that the care provided by Eldon Lodge was below the standard of care, and that their failure to provide appropriate treatment in a timely fashion caused Mr [A]’s death.

4. Review of clinical records

For each question, I am asked to advise on what is the standard of care and/or accepted practice? If there has been a departure from the standard of care or accepted practice, how significant a departure do you consider this to be? How would it be viewed by your peers? Recommendations for improvement that may help to prevent a similar occurrence in future.

In particular, comment on:

• • Mr [A]’s medication regimen and whether this was administered appropriately.
  • The management of Mr [A]’s weight.
  • The care provided to Mr [A] from 25 July 2021 until his hospitalisation, including the coordination of care with Mr [A]’s GP and whether there was any indication for escalation prior to 29 July 2021.
    
    

Background

Mr [A], aged 92 years, was admitted to the rest home community at Eldon Lodge from his own home on 7 December 2020 due to increasing healthcare needs. His medical history included congestive heart failure, dementia, prostate cancer, panhypopituitarism requiring long-term steroid medication, and chronic pain.

According to clinical file information, Mr [A] required moderate assistance with personal care requirements. He was independently mobile with the assistance of a walking stick and engaged in a range of care home activities. He required supervision with meals and supportive care and redirection from rest home staff related to his history of cognitive impairment.

On 25 July 2021, Mr [A] presented with upper respiratory symptoms. On 26 July 2021, he was seen by his general practitioner (GP) and prescribed an antihistamine and cough syrup medication. On 28 July 2021, Mr [A] was seen by his GP and commenced on antibiotic therapy. On 29 July, Mr [A] was transferred to hospital via ambulance with symptoms of fever, respiratory distress, and hypoxia, and diagnosed with community-acquired bacterial pneumonia. A decision was made for supportive comfort care, and Mr [A] passed away [in early] August 2021. I extend my condolences to Mr [A]’s family.

a) Mr [A]’s medication regimen and whether this was administered appropriately

On review of the clinical file documentation, including medication administration records, it appears Mr [A] received all prescribed medication as charted by the GP during the timeframe in question. There are no entries on the electronic administration record by nursing staff that refer to Mr [A]’s regular prescribed medications being withheld or refused during the month of July 2021. While the electronic short course prescription record was not included in the evidence bundle, the electronic short course medication administration record reflects that Mr [A] received the prescribed additional medications as outlined in the GP consultation records on 26 July and 28 July 2021:

• 26 July: Likely viral URTI, charted anti-tussive and cetirizine for symptoms.
• 28 July: Possible LRTI, start Augmentin, increase hydrocortisone.

Panhypopituitarism protocol

According to Lippincott Nursing 2022, panhypopituitarism refers to decreased secretion of pituitary hormones related to diseases of the hypothalamus or pituitary gland. It is a chronic disorder that can cause an exaggerated inflammatory response related to a cortisol deficiency and increase vulnerability to infection.

As evidenced in Enclosure 1: Medication Regime, Mr [A] was prescribed regular oral hydrocortisone three times daily in varied doses. His PRN [as needed] medication prescription, page 3, provides instructions and indications for additional doses of hydrocortisone, referencing his panhypopituitarism protocol, page 4. The flow diagram provides clinical guidance for medication titration in the event of acute illness, such as a respiratory tract infection.

Following the GP visit on 28 July 2021, the medication administration record shows that Mr [A] received his regular dose of oral hydrocortisone 2.5mg at 16.03hrs followed by an additional PRN dose of hydrocortisone 2.5mg at 1747hrs, as per GP’s orders.

[Please refer to PDF version of this report to view image]

 

I note Mr [A]’s nursing care plan does not provide specific guidance concerning the management of panhypopituitarism, the potential impacts to inflammatory responses, and related nursing responsibilities to care and safety needs. While the medication prescription provides an alert to long-term steroid use, it would be accepted practice to reflect complex medical needs within the InterRAI assessment and nursing care plan. From the evidence reviewed to respond to this question, it appears that Mr [A]’s medication regimen and administration was appropriate but lacked documentation in InterRAI and nursing care plans and would be viewed similarly by my peers. Departure from accepted practice: Mild.

Further clinical advice in relation to medication management

There is evidence of concern raised by Mr [A]’s EPOA, Mrs [B], in care record entries and resident case conference meeting minutes 8 July 2021 regarding the appropriate timing of administration and suitability of medications. Points of concern relate to the application of topical Antiflamme and administration of oral omeprazole, M-Eslon, and fentanyl. The organisation’s Medication Management policy provides comprehensive guidance regarding administration and documentation responsibilities. As outlined in the policy, the medication-competent staff member is responsible for administering medications to residents as per the prescriber’s instructions. According to Mr [A]’s medication prescription, omeprazole was prescribed daily at breakfast. Published consumer health guidance indicates the medication may be taken with or without food, in accordance with the prescriber’s orders. I note the RN escalated these concerns to the GP for review and adjustment, which is in line with accepted practice standards.

On 28 July 2021, Mr [A] presented with shortness of breath and oxygen saturation levels of 88%. As reflected in nursing progress notes and the medication administration record, the duty registered nurse administered oxygen at 4L/minute via nasal prongs, as a nurse-initiated medication, prior to paramedic support.

The Medication Management policy (reviewed September 2021) does not provide specific information related to short-course medications, nurse-initiated medications, or oxygen management, particularly during medical emergencies. As outlined in Medicines Care Guides for Residential Aged Care 2011, referenced in the policy, oxygen should be treated like any other medication for administration and prescribed on the medication chart with orders for specific monitoring and supported by guidance in a nursing care plan. As an improvement opportunity, I recommend strengthening the policy to address the identified discussion points.

b) The management of Mr [A]’s weight

The interRAI assessments completed 17 December 2020 and 13 June 2021 indicate Mr [A] tolerated a normal diet and was able to eat and drink with moderate assistance from staff. Nursing notes indicate he required supervision and redirection from staff due to cognitive impairment. As outlined in his care plan, Mr [A] had breakfast and dinner in his bedroom to reduce distractions and his midday meal in the dining room with peers.

Clinical records and the nutritional requirements form show Mr [A] was on a restricted fluids plan of two litres daily due to congestive heart failure. GP notes refer to pitting oedema with observations of lower leg swelling from toe to knee, and Mr [A] was on prescribed diuretic therapy to support this. There is discussion of fluid monitoring charts and monthly weighs being completed by staff during Mr [A]’s admission to the care home. This is in line with the Nutrition and Hydration policy (2021), which outlines care responsibilities with weight management. The policy provides guidance regarding unplanned weight loss and related nursing interventions. This approach is in line with the Health Quality & Safety Commission’s Frailty Care Guides, which provide guidance about accepted practice standards to support clinical judgement and inform staff practice (HQSC, 2019).

According to the weight record form, Mr [A]’s weight on admission was 81kg with a BMI [body mass index] of 27.94. His weight declined to 77.4kg in February, then 76.8kg in March 2021. Mr [A]’s EPOA expressed concern to staff about his weight loss, and he was commenced on Ensure, a nutritional supplement, by the GP on 3 March 2021. Medication administration records indicate he received the supplement twice daily as prescribed. The nutritional profile and nursing care plan shows Mr [A] was offered a high-calorie diet with snacks as per accepted practice standards. This is supported in resident survey findings and meeting minutes.

Monthly weight records show Mr [A]’s weight continued to decline between March and July 2021 to 71.7kg. It is unclear why the frequency of weighing was not increased as per policy guidelines for unintentional weight loss during this timeframe; however, there is evidence of regular GP review and discussion of weight variation during visits. There is evidence in clinical notes in June 2021 of external consultation with a community-based aged care Nurse Practitioner regarding Mr [A]’s weight management.

From the evidence reviewed to respond to this question, it appears Mr [A]’s weight management was in line with acceptable practice and would be viewed similarly by my peers. Departure from accepted practice: Nil

c) Whether the identification and escalation of care concerns was timely.

The clinical records show Mr [A] was regularly seen by medical practitioners during his admission to the care home. As his needs changed, wider support was sought from allied health professionals to provide clinical input to his care. GP notes reflect his weight was trending down with increasing periods of restlessness and confusion and changes in mood and behaviour. A referral was sent to Mental Health Services for Older People on 6 June 2021 with the view to have Mr [A] assessed for a higher level of care. He was seen by a team member on 24 June 2021, supported by his daughter and EPOA. Dr’s notes 6 July reflect the involvement by Older Adult, Rehabilitation and Allied Health Services (ORA) in Mr [A]’s care. The care record reflects that Mr [A] was last seen by his regular GP on 6 July. He was seen by a new GP on 26 July 2021.

Mrs [B] has expressed specific concern regarding the care provided to Mr [A] from 25 July 2021 until his hospitalisation on 29 July 2021, including the coordination of care with Mr [A]’s GP and whether there was any indication for escalation prior to 29 July 2021.

Mr [A]’s Advance Directive Form and Future Care Directions, signed and dated 6 December 2020, elects to receive treatments which look after my comfort and dignity rather than treatments to prolong my life. I do not want to be resuscitated.

The document reflects a Do not attempt resuscitation (DNR) order signed by his GP 19 January 21. Part D. ‘Desired level of care in the event of acute medical illnesses’ reflects a decision for comfort care, no hospitalisation unless there is traumatic injury, and no antibiotic therapy — not to prolong life but only for comfort.

Entries from qualified and care staff in the care record in July 2021 indicate Mr [A] was experiencing episodes of confusion and unwellness prior to being seen by the GP on 26 July. An RN entry on 2 July states his daughter reported her father was “out of sorts”, sleepy and confused, querying medication involvement. During the timeframe in question, nursing progress notes reflect ongoing concern raised by Mr [A]’s daughter regarding his health status. An entry on 25 July, AM shift, states that Mr [A]’s daughter expressed concern about a “rattly” cough, and that he was not as aware as usual. The RN reported a mild cough with green sputum, mild nosebleed, and observed reduced mobility. The RN on PM shift reported restlessness with wandering behaviour and confusion. Nursing assessment occurred and PRN antipsychotic medication was administered.

On 26 July, an RN entry states Mr [A] appeared generally unwell and was seen by his GP regarding cough and cold symptoms. Dr’s notes indicate Mr [A] had a likely viral upper respiratory tract infection (URTI) and was prescribed an antihistamine and cough syrup. There is no discussion within the clinical record regarding indications to commence the hydrocortisone protocol. Due to a change in clinic time, Mrs [B] was unable to be present for the GP visit. As outlined in the consumer correspondence, Mrs [B] asked to participate in Mr [A]’s GP consultation via telephone; however, the family contact record indicates Mrs [B] was updated after the GP visit.

There is no entry in the submitted electronic care record for 27 July 2021. The timeline within the provider response letter refers to the delivery of personal care and administration of prescribed medications; however, there is no discussion of Mr [A]’s health status or vital signs.

Entries in the care record for 28 July 2021 reflect family concern with Mr [A]’s health. RN statements describe a productive, chesty cough with excess phlegm and nasal discharge. Vital signs indicate a raised temperature of 38.1°C, oxygen saturation levels on room air at 92%, a heart rate of 50 bpm, and respiration rate of 23/min. There is no record of a blood pressure reading during this time. The clinical notes show Mr [A] was reviewed by the GP and reportedly presented with reduced air entry bibasally, with right basal crepitus indicating a possible lower respiratory tract infection (LRTI). According to file information, he was commenced on antibiotic therapy and an increased hydrocortisone dose. Given Mr [A]’s advance directive and family concern, it is unclear why a case conference did not occur between the GP, Clinical Manager, and Mr [A]’s EPOA at this time to discuss his goals for care and ongoing management.

The care record shows Mr [A] continued to present with signs of decline overnight. Nursing entries describe Mr [A] as unsettled, unsteady, confused, short of breath and very chesty. At 0130hrs on 29 July, Mr [A]’s vital signs were T.37.9°C, HR.107bpm, RR.26/min, O2 sats 85% on room air, BP 122/53. Progress notes indicate on-duty staff provided supportive care. The RN on the AM shift assessed Mr [A] and called an ambulance for assistance. It is an accepted practice to seek paramedic support for a medical emergency in residential aged care. I note from the file evidence, the paramedic assessment showed Mr [A] presented with symptoms of fever, respiratory distress and hypoxia — T.37.1°C, HR 170bpm, RR 40/min, O2 sats 71% on room air. He was transferred to hospital for further assessment and diagnosed with community acquired bacterial pneumonia and sepsis.

As outlined in the Frailty Care Guides, sepsis is a medical emergency (HQSC, 2019). New Zealand’s Best Practice Advocacy Centre (BPAC) created clinical guidelines in partnership with the UK’s National Institute for Health and Care Excellence (NICE) titled “Sepsis: Recognition, Diagnosis and Early Management”^[8] as a tool for healthcare providers, consumers and care teams to refer to. The document outlines identified risk factors for developing sepsis, which includes people aged over 75 years, have an impaired immune system, take long-term steroids, or have a breach of skin integrity (BPAC, 2018). The Sepsis Screening tool provides guidance about signs of acute deterioration to inform clinical decision making. Partnered with the early warning signs STOP AND WATCH tool and ISBAR communication tool.

Clinical file documentation reflects that Mr [A]’s family were very supportive and actively involved in his care while resident at Eldon Lodge. Prior to admission, Mrs [B] was Mr [A]’s primary carer and advocate as his EPOA. Having open communication and a shared understanding of care responsibilities is particularly important for families who are acting on behalf of a resident living with a diagnosis of dementia. There are regular entries in the electronic care record by nursing staff informing the EPOA of GP visits, fall events, changes in health status such as wound care, or changes to the clinical plan of care. The submitted evidence reflects that concerns raised by family members were escalated by care staff to the registered nurse for follow up.

Change in cognition, behaviour or mental state, as reported by NOK

• • Hyperthermia or hypothermia <36 or >37.5
  • Tachycardia HR > 100bpm
  • Tachypnoea > 24 respirations/minute
  • People who are older, and frail may not develop a fever
  • Unclear if Mr [A] had recent bloods taken which may have shown raised inflammatory markers and increased WBC count to indicate potential systemic infection

The ARRC Services Agreement and Health and Disability Service Standards require service providers to acknowledge and involve the consumer and their nominated representatives in all aspects of care. This includes notifying the nominated person in a timely way of any change in the resident’s health condition, any identified risk or concern regarding their care and safety needs, or of any adverse event. As the EPOA for Mr [A], Mrs [B] as the consumer’s decision-maker, has the right to be informed and to give informed consent to proposed changes to an agreed plan of care. Care decisions are made in partnership with the EPOA and registered nurses at the care home, and evidence of these interactions is required to be documented in the resident’s family contact record, care plan, progress notes and meeting minutes.

The provider response letter has acknowledged and apologised for any miscommunication with Mrs [B] regarding Mr [A]’s weight management and related care. The provider investigation has identified opportunities for improvement with communication tools and interaction with resident’s nominated representatives. There is discussion of proposed recommendations in the provider response and further evidence of a completed corrective action plan was provided.

From the evidence reviewed to respond to this question, it appears that the identification and escalation of care concerns (as stated in 4 points below) was not timely and would be viewed similarly by my peers. Departure from accepted practice: Moderate

1. Delay in acute treatment from 25 July 2021 of increasing signs of respiratory infection which resulted in a medical emergency and hospitalisation on 29 July 2021. The expected timeframe for notification of acute illness is the same day, the documented evidence indicated that GP was notified on 26 July 2021.
2. Non-adherence to follow resident’s specific medical protocol for management of panhypopituitarism. A delay of 3 days in commencing additional hydrocortisone treatment (28 July) at the start of the acute illness on 25 July 2021.
3. Poor communication and lack of support provided to enable EPOA daughter (advocate) to meet or discuss medical concerns with the newly contracted GP. Daughter requested a discussion with new GP during the consultation (on 28 July) which did not occur.
4. Lack of evidence of protocols for medical emergencies.

5. Clinical advice

I note that the events occurred during the COVID-19 pandemic period 2020–2022 and acknowledge the impacts of COVID-19 pandemic restrictions, public health measures and related challenges for residents, family/whānau, care home teams and health service providers during this time.

Communication of any change in resident care is a priority for discussion at shift handover, and sharing of any relevant information between clinical and non-clinical teams, such as a change in dietary requirements, is particularly important to ensure the resident’s care and safety needs are consistently maintained. Escalation of acute changes to resident’s condition can be improved with the use of the ISBAR (Introduction, Situation, Background, Assessment, Recommendation) communication tool from qualified nursing staff with GP.

In addition to the Provider’s list of corrective actions, I recommend that the care home implements medical emergency protocols and a review of care planning process to ensure that the resident’s individual needs are clearly documented.

I also recommend the care home team complete additional education on communication with and about older people and their family/whānau, including strategies for ensuring changes in resident needs are safely communicated to minimise the risk of a similar occurrence in the future. To support this approach, I recommend that staff complete the new online modules for further learning https://www.hdc.org.nz/education/online-learning/

Addendum: Additional dates provided for moderate departure part c) on 8 April 2025.

 

Dr Isabella Wright, RN, NP, Doctor of Health Science

Nurse Advisor (Aged Care)

Health and Disability Commissioner

References

Best Practice Advocacy Centre New Zealand. (2018). Sepsis: recognition, diagnosis and early management. https://bpac.org.nz/guidelines/4/docs/Sepsis.pdf

Health and Disability Commissioner. (2022). Online Learning. https://www.hdc.org.nz/education/online-learning/

Health Quality & Safety Commission. (2019). Frailty Care Guides. http://www.hqsc.govt.nz/

Lippincott — Overview | Sepsis: recognition, diagnosis and early management | Guidance | NICE’