Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

1. This Office received four complaints relating to the standard of care provided to residents with high and complex needs living at an aged residential care facility, Eileen Mary Residential Care and Retirement Village (the care facility), operated by Eileen Mary Age Care Limited[1] between 2022 and 2024. At the time of the events, the care facility was owned by Eileen Mary Age Care Limited. On 13 November 2024, the care facility was sold to new owners. The four complaints have been combined into a single investigation.
   
   
2. Although the facility continues to operate as ‘Eileen Mary’, ownership transferred to a new operator in November 2024. The complaints investigated here relate to historical events that occurred before that change. Since taking over in late 2024, the new operator reports that investment in care systems and staffing has improved the standard of care, occupancy, and resident satisfaction.
   
   

Information gathered

Mrs A

3. Mr A complained about the care provided to his late mother, Mrs A, in 2022. He stated that maggots had been found on her legs during a routine wound dressing change, and he requested that the Health and Disability Commissioner (HDC) review the care provided to her.
   
   
4. Mrs A, aged 94 years at the time, was admitted to the care facility on 21 January 2022 for hospital-level care after recent hospitalisation for exacerbation of congestive heart failure (CHF).[2] In addition to CHF, Mrs A had a history of dementia, leaking bilateral leg oedema,[3] and wounds on her legs caused by the leaking. Mrs A required extensive assistance with activities of daily living, including personal cares and mobility.
   
   
5. On admission, Mrs A’s long-term care plan (LTCP) noted that she had very dry, fragile and itchy skin that was prone to breakdown. The LTCP also recorded that Mrs A had a stage one (superficial) pressure injury[4] on her left leg and that she needed support to prevent the risk of pressure injuries worsening.
   
   
6. A wound care plan was developed for a ‘small open area’ that was noted on the left lower leg on 23 January 2022. No photos or measurements of this wound were taken, as required by Eileen Mary Age Care Limited’s Wound and Skin Care Management Policy (dated July 2024). Minutes of a Toolbox Talk (dated 20 May 2022) with Eileen Mary Age Care Limited staff state that the care facility manager was to purchase a phone so that staff could take photos, which suggests that staff did not have equipment to take photos at the time of the events.
   
   
7. The wound care plan instructed staff to cover the wound with absorbent pads and to change the dressing every two days. The care plan also advised staff to check the dressing every shift and to replace the dressing if it was wet.
   
   
8. Clinical records show that the wounds were reviewed regularly, and on 9 February 2022 it is documented that the absorbent dressings needed to be covered with two layers during replacement. No other concerns were recorded until 20 February 2022.
   
   
9. On 20 February 2022, a nurse found maggots in Mrs A’s left lower leg wound during a routine dressing change. The moisture levels and exudate level of the dressing prior to its change is not recorded. The nurse contacted the on-call care facility manager, who advised the nurse to wash the wound with warm water and Betadine,[5] which was completed. Hato Hone St John ambulance service was called for further support. The ambulance service assessed the wound and advised Eileen Mary Age Care Limited staff to follow up with the general practitioner (GP) the following day. A swab of the wound was taken to check for infection. No photos of the maggots or the wound were taken.
   
   
10. On 21 February 2022, Mrs A was assessed by the GP, who advised staff to continue Betadine washes, follow up to obtain the wound swab results to ensure there was no infection, and to review the wound if it deteriorated further.
    
    
11. An adverse event report was completed on 23 February 2022, which noted that fluid in Mrs A’s wound may have attracted flies from a nearby sheep paddock during the warm weather and fly season. The family were informed of the adverse event. The adverse event report did not record the size, quantity, or a picture of the maggots. Clinical records note that Mrs A’s neighbours had brought in fly spray and a portable fan to remove the flies from her room. No other pest control measures were implemented by Eileen Mary staff to manage the flies.
    
    
12. Sadly, Mrs A passed away after the complaint was made.
    
    
13. Mr A was given the opportunity to comment on the ‘information gathered’ section of the provisional report. He did not provide any comments.
    
    

In-house clinical advice

14. In-house clinical advice was sought from aged care advisor Registered Nurse (RN) Hilda Johnson-Bogaerts (Appendix A). She noted the following:

• • The wound care plan was acceptable. However, a dressing product with stronger absorbency could have been used, and if the bandage was left wet this would be a mild departure from the accepted standard of care.
    
    
  • The wound management policy and documentation of wound care — mild to moderate departure from the accepted standard of care.

15. In addition to the above, RN Johnson-Bogaerts advised that there were limited post-event remedial actions, a lack of earlier action on the presence of flies, and a lack of activation of pest-control measures.

Decision — adverse comment

16. I express my sincere condolences to Mr A and his family for Mrs A’s passing.
    
    
17. Having reviewed the clinical records and response from Eileen Mary Age Care Limited, I am critical of the care provided to Mrs A by Eileen Mary Age Care Limited. I concur with RN Johnson-Bogaerts and consider that the wound management plan and the remedial actions in response to finding maggots was inadequate overall. Specifically, I am critical of the lack of pest-control measures implemented by Eileen Mary Age Care Limited, the standard of adverse event reporting, and the lack of compliance with the Wound and Skin Care Policy. I am concerned that Eileen Mary Age Care Limited considered that the care provided to Mrs A was appropriate.
    
    
18. I am also concerned to learn that Eileen Mary Age Care Limited placed reliance on Mrs A’s neighbour to contain the pest, rather than actively taking the lead. In my opinion, Eileen Mary Age Care Limited failed to demonstrate the level of advocacy necessary to minimise the risk of further harm to Mrs A.

Ms B

19. HDC received a referral from the Coroner regarding the care provided to the late Ms B, who had passed away due to complications from advanced breast cancer. The Coroner stated that Ms B’s GP, Dr G, at the local GP centre, raised concerns around the timely recognition of Ms B’s breast changes and escalation of care by Eileen Mary Age Care Limited in 2023 and 2024.
    
    
20. Ms B, aged 64 years at the time, was admitted to the care facility on 1 May 2023 for hospital-level care. She had a history of right middle cerebral artery infarct[6] with left-sided weakness, anxiety, and intellectual disability with limited ability to communicate, and she was fully dependent on staff for undertaking activities of daily living. Eileen Mary Age Care Limited said that Ms B did not have a breast cancer diagnosis or a family history of breast cancer when she was admitted to its care home. In contrast, Health New Zealand | Te Whatu Ora (Health NZ) documentation shows that Ms B’s family had a history of maternal breast cancer and a non-maternal history of other forms of cancer.
    
    
21. Ms B’s LTCP states that she could not verbalise her pain levels and that she required paracetamol when she was calling out or appeared unsettled.
    
    
22. No non-verbal pain assessment tools, such as the Abbey Pain Scale,[7] were being used over the course of Ms B’s admission, as required by Eileen Mary Age Care Limited’s Pain Management Policy (dated 2023) and the Adverse Health — Early Warning Policy (dated March 2023), which state that non-verbal assessments are to be used in residents who are unable to verbalise pain or in those who have cognitive impairment. However, progress notes make regular references to Ms B ‘calling out’, ‘screaming’, and being ‘unsettled’ and ‘restless’. Progress notes show that Ms B experienced these behavioural symptoms almost daily over March and April 2024, which required administration of midazolam[8] and quetiapine.[9] Primary care notes on 2 May 2024 record that Ms B had been ‘noted by staff to be agitated over recent weeks.’ This was not escalated to Ms B’s Nurse Practitioner (NP) or GP for review.
    
    
23. Ms B’s LTCP states that she was at risk for skin breakdown and was at a moderate risk for developing a pressure injury. Eileen Mary Age Care Limited told HDC that skin assessments occur regularly for residents. Progress notes do not explicitly record whether skin assessments had been undertaken every shift; however, there are references to redness on Ms B’s sacrum, left leg, and right arm and armpit, which suggests that skin checks did occur. The progress notes do not record whether the redness on the skin was assessed as a pressure injury. Monitoring charts also show that regular turns were being completed for pressure injury prevention.
    
    
24. Progress notes record that, on 25 April 2024, a caregiver noted a lump (which was intact) on Ms B’s right breast. This was the first time breast changes had been recorded by Eileen Mary staff in the clinical records. The lump was escalated to a nurse, who added Ms B to the GP/NP list for a clinical review. The nurse did not assess the size of the lump or signs of any redness, swelling, or pain on palpation. There was no further documentation about the breast lump until 30 April 2024.
    
    
25. While Ms B was waiting for a review by the GP/NP, progress notes record that a small lesion (wound) had developed on the right breast on 30 April 2024. A nurse cleaned and dressed the lesion and noted another lump on the left breast. A wound care plan and an incident form were completed, and a photograph of the wound was taken, in accordance with Eileen Mary Age Care Limited’s Wound and Skin Care Management policy. The wound care plan recorded the size of the wound and that there was mild exudate[10] but no moveable mass. No other assessment of the wound occurred. The nurse did not escalate the wound to a senior nurse or clinical manager for advice, and the nurse did not report changes in the breast to the GP/NP for review. Eileen Mary Age Care Limited did not provide any policies relating to escalation of care, despite HDC’s request.
    
    
26. An NP review of the breast occurred on 2 May 2024. The NP recorded that Ms B had ‘a hard at least 5cm by 4cm mass’ on the right breast and ‘approx[imately] 4cm × 2cm’ mass on the left breast. The NP noted that this may have caused Ms B’s overall deterioration in recent months and Ms B’s recent agitation. Dr G told HDC that she is concerned that Ms B’s wound had been present for longer than had been reported by staff. The NP referred Ms B to hospital for investigation of the breast lumps.
    
    
27. The hospital diagnosed Ms B with advanced breast cancer, and Ms B returned to Eileen Mary on 6 May 2024 for palliative care. Progress notes show that hospice was contacted and that hospice input occurred. However, no end-of-life care plan was commenced by Eileen Mary Age Care Limited, as outlined in the Te Tāhū Hauora Health Quality & Safety Commission (HQSC) Frailty Care Guides (2023).[11] Eileen Mary said that staff discussed the palliative care plan with Ms B’s family, who wished for her to receive comfort cares. However, details of the palliative care plan and discussions held with the family are not documented in the clinical records.
    
    
28. Sadly, Ms B passed away in May 2024.
    
    
29. Ms B’s sister, Ms H, was given an opportunity to comment on the ‘information gathered’ section of the provisional report. Ms H felt that staff did not have the knowledge to look after people with special needs and was concerned about the end-of-life care provided to Ms B. She trusted them to care for her sister when she could not and is disappointed to hear what has happened. Ms H hopes that the care facility’s standard of care will improve in the future.
    
    

In-house clinical advice

30. RN Jane Ferreira provided in-house clinical advice (Appendix B). She noted the following departures from accepted standards of care:

• • Lack of recognition of concern and timely escalation of breast lump and lesion — mild to moderate departure.
  • Lack of end-of-life care plan, lack of recognition and management of pain — mild to moderate departure.

Decision – breach

31. I express my sincere condolences to Ms B’s family for her passing.
    
    
32. Having reviewed the clinical records and response from Eileen Mary Age Care Limited, I find that Eileen Mary Age Care Limited breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights. I concur with RN Ferreira that there was a lack of timely recognition of the changes in Ms B’s breast. In my opinion, Eileen Mary Age Care Limited staff did not utilise critical thinking to establish the underlying reasons for the acute changes in Ms B’s health. Had appropriate and holistic assessments of Ms B’s ongoing pain and behavioural changes occurred in conjunction with the changes in her breast, her care may have been escalated to the GP/NP earlier. I am also critical of the lack of an end-of-life care plan to support the last days of Ms B’s life.
    
    
33. I take this opportunity to remind Eileen Mary Age Care Limited of the immense trust placed on healthcare providers by vulnerable residents such as Ms B, and their families, to care for and advocate for their wellbeing.

Mrs D

34. HDC received a complaint from Ms C regarding the care provided to her late mother, Mrs D, by Eileen Mary Age Care Limited in 2022. Ms C raised concerns around the admission process, lack of communication from staff, pain management, and wound care.

Admission

35. Mrs D, aged 94 years at the time, was admitted to the care facility on 21 October 2022 for short-term care. Mrs D was transferred from hospital, where she had received care for a large pressure injury on her hip and buttock, increasing frailty, reduced mobility, and a urinary tract infection. Prior to her hospitalisation, Mrs D had lived at home with her husband and received regular support services. Hospital records show that Mrs D was awaiting a needs assessment to determine the suitability of her returning home. Mrs D had a history of advanced dementia and poor oral intake, and she required full assistance with activities of daily living.
    
    
36. Eileen Mary Age Care Limited’s Admission Policy and Procedures document (undated) states that the resident or their representative is to sign an Admission Agreement within 10 working days of the admission and ideally on the day of the admission. Ms C was Mrs D’s activated Enduring Power of Attorney (EPOA) for personal care and welfare. The Admission Agreement was signed on 25 October 2022 by Mrs D, and Eileen Mary Age Care Limited said that two nurses were involved in this process. Ms C told HDC that Mrs D was asked to sign her Admission Agreement despite having dementia and not having the capacity to understand the information written in the agreement. Eileen Mary Age Care Limited acknowledged that it did not follow due process and indicated that this had occurred because there was confusion around the status of EPOA activation. Eileen Mary Age Care Limited apologised to Ms C for this experience.
    
    
37. Progress notes do not record any discussions held with the EPOA regarding the admission process, such as the resident’s expectations and needs, and the complaints process, as required by the Admission Policy and Procedures document.
    
    
38. The Admission Policy and Procedures document states that a GP/NP must be notified of any new admissions into the care home and must complete an examination and initial consultation with the resident within two working days of the admission. Clinical records do not show that a medical admission occurred. Eileen Mary Age Care Limited said that Mrs D remained under the care of her own GP, who was responsible for her prescriptions and charting of medications. However, Eileen Mary Age Care Limited also said that there are no records of a virtual or telephone consultation being held with Mrs D’s GP. GP records show that Eileen Mary Age Care Limited staff made only one contact with the GP, on 9 November 2022 regarding Mrs D’s constipation.
    
    
39. The Admission Policy and Procedures document states that a nurse must complete an initial comprehensive assessment on admission to determine the presence of an acute illness and define the initial care planning, including signs and symptoms monitoring, and reporting processes. An initial care plan was started, which noted Mrs D’s mobility, skin care and self-care, sleeping, and sensory and communication needs. A pressure injury risk assessment was completed on admission, which noted that Mrs D was at a high risk for developing pressure areas. However, an LTCP was never commenced, which is required by Eileen Mary Age Care Limited’s Clinical Documentation and Report Writing Policy (dated March 2023). Eileen Mary Age Care Limited acknowledged that an LTCP should have been developed.
    
    
40. The first progress note entry on 21 October 2022 recorded that Mrs D had been admitted with a ‘dressing [on the] left hip’. However, no wound assessment, pain assessment, or short-term care plan (STCP) for the wound were commenced, as required by the Clinical Documentation and Report Writing policy. Turn charts also did not commence until 12 November 2022.
    
    
41. Progress notes record that Mrs D ‘complained [of] pain while moving’. No Abbey Pain Assessments, STCP, or pain management care plan were completed for Mrs D’s pain, as required by Eileen Mary Age Care Limited’s Pain Management policy and the Clinical Documentation and Report Writing policy.
    
    
42. A continence assessment was completed on 21 October 2022, which noted that Mrs D required assistance with her urinary and faecal incontinence. Mrs D also had a urinary catheter and experienced faecal incontinence and constipation (requiring manual evacuation[12]), but bowel and bladder function monitoring charts were not commenced. An internal audit report completed by Eileen Mary Age Care Limited (dated March 2023) found inconsistencies in the completion of monitoring charts.
    
    
43. A nutritional assessment was completed, which noted Mrs D’s nutritional requirements, her history of weight loss, and her risk for malnutrition. No discussions were held with the family about Mrs D’s nutritional needs and food preferences. Mrs D was on a nutritional supplement and had poor food intake. However, monitoring charts for food and fluid intake were not commenced.
    
    

Wound care

44. In November 2022, Mrs D passed away as a result of sepsis[13] from her infected pressure injuries. Ms C is concerned about the standard of wound care provided to Mrs D and told HDC that Mrs D did not have an infection when she was initially admitted to the care facility.
    
    
45. The Wound and Skin Care Management Policy notes that a skin integrity check must occur on admission. The policy states that when a resident presents with a wound, a description of the area and the treatment required for the wound must be documented in the progress notes. A nurse is to assess the wound and develop a wound management plan on the day the wound is identified.
    
    
46. A wound care plan was developed and commenced for Mrs D’s sacral pressure injury on 12 November 2022 (22 days after admission). Eileen Mary Age Care Limited acknowledged that there was an unacceptable delay in commencing a wound care plan. The wound care plan noted that this was a stage 1 pressure area and that there were no breaks in the skin. A photograph was taken, which shows reddened sacral skin with no breaks. The next wound review/dressing change was listed for 19 November 2022 (one week later).
    
    
47. The wound was reviewed again on 16 November 2022 (four days after the initial review and before the next dressing change was due). The sacral pressure injury had developed necrotic[14] tissue and was sloughy.[15] A photograph shows that the entire wound was black with reddened flaky edges. The wound was debrided[16] and cleaned, and the next wound review/dressing change was listed for 19 November 2022. Eileen Mary Age Care Limited accepted that the wound care plan and the dressing regimen was inadequate given the severity of the wound. Eileen Mary Age Care Limited acknowledged that the dressing should have been changed more frequently.
    
    
48. Eileen Mary Age Care Limited stated that a district nurse was contacted regarding the wound, and Eileen Mary Age Care Limited staff were advised that it was the responsibility of its staff to manage the wound. Eileen Mary Age Care Limited has no copy of any referrals completed to the district nurse, and the progress notes do not indicate that this occurred.
    
    
49. Eileen Mary Age Care Limited’s Wound and Skin Care Management Policy states that, if the wound healing is prolonged or if there are signs of infection, the resident’s GP/NP must be consulted to review the wound and advise on further treatment. However, the GP/NP was never consulted regarding the wound.
    
    

Acute deterioration

50. Progress notes show that Mrs D had reduced food and fluid intake from 16 November 2022 and that she either declined meals or ate a minimal amount. Eileen Mary Age Care Limited acknowledged that no STCP was developed to monitor Mrs D’s weight or changing appetite levels. Eileen Mary Age Care Limited also acknowledged that these changes could have been an indicator of Mrs D’s deteriorating health, and staff could have consulted with the GP/NP regarding these matters. Mrs D’s family were not contacted regarding the changes in her food and fluid intake.
    
    
51. In the early hours in mid-November 2022, Mrs D deteriorated. Progress notes record that she appeared pale, had a rapid respiratory rate (24 breaths per minute),[17] poor oxygenation levels (78%),[18] and a rapid heart rate (120 beats per minute).[19] The nurse caring for Mrs D contacted the clinical nurse lead and the family to update them. Thereafter, an ambulance was called.
    
    
52. The ambulance service’s entry into the care facility was delayed for 30 minutes because no access to the care facility was provided. Eileen Mary Age Care Limited said that its expectation is that someone would monitor the care facility entry to allow external services to access the resident promptly. Eileen Mary Age Care Limited acknowledged that this did not occur and that this delayed Mrs D’s care by the ambulance service and her transfer to hospital.
    
    
53. Documentation from the ambulance service indicates that, on arrival, there were concerns about the care provided by Eileen Mary Age Care Limited. The ambulance service advised Eileen Mary Age Care Limited staff to administer oxygen to Mrs D because of her low oxygenation levels. However, the nurse caring for Mrs D refused to initiate this intervention as oxygen had not been prescribed. Eileen Mary Age Care Limited said that the nurse had consulted the clinical nurse lead, who had instructed the nurse not to administer oxygen. This resulted in the ambulance staff forcibly insisting that oxygen be administered. Eileen Mary Age Care Limited acknowledged that this was not acceptable and that nursing staff clearly required additional education around the use of emergency medicines.
    
    
54. Documentation from the ambulance service also indicated that there was poor handover from Eileen Mary staff to the ambulance service. It is documented that Eileen Mary Age Care Limited staff were unable to tell the ambulance service when the wound dressing had been changed. It is noted that the dressing was ‘old’, ‘tattered at the edges and in parts not even stuck to skin’, ‘weepy’, and ‘pungent’, and that the wound appeared necrotic. The ambulance service noted that Mrs D was significantly emaciated, with a reduced Glasgow Coma Score (GCS).[20] Eileen Mary Age Care Limited staff told the ambulance service that Mrs D had always had a reduced GCS. In contrast, Ms C told HDC that Mrs D had been ‘very bright, [a]lert, and bubbly’ on admission. Eileen Mary Age Care Limited documentation does not show that a GCS was recorded during Mrs D’s admission.
    
    
55. Mrs D was transferred to hospital shortly after ambulance staff had assessed her. On arrival at the hospital, staff noted that Mrs D had a necrotic wound and sepsis. Comfort cares were initiated and, sadly, she passed away in mid-November 2022.
    
    
56. Ms C is concerned about the delays in Eileen Mary Age Care Limited staff in informing her that Mrs D had been ‘actively dying’. Ms C said that she was informed only when Mrs D had deteriorated in the early hours. Ms C stated that the lack of communication meant that her family were unable to spend time with Mrs D before she died. Eileen Mary Age Care Limited said it is regretful that Mrs D’s family were contacted about Mrs D’s deterioration only in the early hours of the day she died, and it acknowledged that the communication with Mrs D’s family was unsatisfactory.
    
    
57. Eileen Mary Age Care Limited acknowledged that the care provided to Mrs D was not of the standard it expected. Eileen Mary Age Care Limited apologised to Ms C for the care provided to Mrs D.
    
    
58. Ms C was given an opportunity to respond to the ‘information gathered’ section of the provisional report. Ms C said she was disappointed and angry that a home entrusted with her mother’s care treated her poorly.
    
    

In-house clinical advice (Appendix C)

59. RN Ferreira noted cumulative moderate to severe departures from the accepted standards of care due to Eileen Mary Age Care Limited’s lack of compliance against its admission process, the standard of communication with Mrs D’s EPOA, the lack of escalation of care to the GP/NP, the standard of wound management, and the lack of recognition of Mrs D’s health changes and decline.

Decision – breach

60. I express my sincere condolences to Ms C and her family for Mrs D’s passing.
    
    
61. Having reviewed the clinical records and response from Eileen Mary Age Care Limited, I find that Eileen Mary Age Care Limited breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights. I agree with RN Ferreira that the necessary admission processes were not followed, that the wound management was substandard, that communication with Mrs D’s EPOA was poor, and that the management of Mrs D’s acute deterioration in November 2022 was inadequate, and I am critical of these failings by Eileen Mary Age Care Limited.
    
    
62. In my opinion, it is clear that Mrs D was deteriorating in the days following her presentation on 16 November 2022. This should have been managed through careful monitoring, holistic assessment of Mrs D’s symptoms, an active partnership with Mrs D’s GP/NP, including ensuring that a medical assessment occurred on admission, and greater oversight of the wound management processes.
    
    

Mrs E

63. Dr G, GP, made a complaint to HDC stating that clinicians at the local GP centre (as her registered practice) were not alerted to Mrs E’s unstageable pressure injury[21] in 2023 and 2024.
    
    
64. Mrs E, aged 83 years at the time, was admitted to the care facility on 5 August 2022 for hospital-level care. Mrs E had multiple comorbidities, including dementia and diabetes mellitus. A Braden pressure injury risk assessment completed on 12 December 2023 showed that Mrs E was at a high risk for developing pressure areas.
    
    
65. Eileen Mary Age Care Limited said that a pressure injury was first noted on Mrs E’s sacrum on 20 August 2023. This was graded as a stage one pressure injury, and the family was notified. Eileen Mary said that an STCP, an alternating air mattress, and a regular turning schedule were put in place to minimise the risk of the pressure area declining. Eileen Mary Age Care Limited said that these interventions were discontinued on 14 September 2023 as the area had improved.
    
    
66. Eileen Mary Age Care Limited said that a further stage one pressure injury was identified on the sacral area on 4 December 2023, and this deteriorated to a stage two[22] pressure injury within three days (on 7 December 2023). The family was updated regarding the wound on 4 December 2023, but no wound management plan or STCP was commenced until 7 December 2023. An incident form for this was completed on 7 December 2023. The HQSC Frailty Care Guides state that support should be sought from a GP/NP when there are signs of wound decline. However, this did not occur on 7 December 2023, when Eileen Mary Age Care Limited said the wound deteriorated.
    
    
67. Clinical records show that an air mattress and a pressure-relieving cushion were implemented, and regular turns were completed. These interventions received oversight from the care facility manager at the time. However, Mrs E’s LTCP was not updated to reflect the wound care requirements. A further incident form completed on 19 December 2023 noted that the wound was not healing and was unstageable.
    
    
68. The HQSC Frailty Care Guides state that support should be sought from a GP/NP and a wound specialist for unstageable pressure injuries. There is conflicting evidence as to when a GP/NP was first notified when the pressure injury became unstageable. An incident form dated 19 December 2023 noted that an ‘ISBAR[23] [form] and photo [were] sent to [the medical centre]’. Eileen Mary Age Care Limited confirmed that this occurred; however, a copy of the ISBAR form and communication records with the medical centre were not provided to HDC. Eileen Mary Age Care Limited said that the GP commenced Mrs E on antibiotics for suspected infection; however, the medication records provided to HDC do not show that antibiotics were prescribed. The GP centre’s clinical records show that, on 11 January 2024, NP I recorded that Mrs E had a pressure injury that was either a stage four[24] or unstageable. NP I recorded that a nurse ‘report[ed] [that the pressure injury] ha[d] only been present for [three] days [but it was] unlikely to be only that time’. This suggests that the medical centre may not have received any correspondence on 19 December 2023, possibly because of the Christmas/new year period.
    
    
69. Eileen Mary Age Care Limited said that the pressure area failed to improve despite the antibiotics, so it sent referrals to the dietician and specialist wound care services. A wound specialist referral was sent on 20 December 2023 and written advice on wound management was provided to the care facility on 12 January 2024, with instructions to contact the wound specialist services if the wound did not improve in two to three weeks.
    
    
70. A dietician referral was completed on 18 January 2024, and the dietician completed an assessment on 13 February 2024. Mrs E’s diet was changed to assist with the healing of the wound. Eileen Mary Age Care Limited said that the wound improved following these interventions. A review by the wound specialist nurse on 9 May 2024 noted that the pressure area, now a stage three,[25] ‘ha[d] improved significantly … and [was] healing well’.
    
    
71. Progress notes refer to pain assessments having been completed, and the medical centre’s clinical records indicate that requests were made for additional pain relief to be charted for Mrs E. However, a non-verbal pain assessment tool was not used, as required by Eileen Mary Age Care Limited’s Pain Management policy, until February 2024.
    
    
72. Sadly, Mrs E passed away in August 2024 after this complaint was received.
    
    

In-house clinical advice (Appendix D)

73. RN Ferreira advised that there were cumulative mild to moderate departures from the accepted standards of care in relation to Mrs E’s pressure area management, the standard of communication with the NP/GP, and documentation practices.

Decision – adverse comment

74. I express my sincere condolences to Mrs E’s family for her passing.
    
    
75. Having reviewed all the available information, I agree with RN Ferreira that there are several areas of concern with respect to the pressure area cares provided to Mrs E, the standard of communication with the NP/GP, and documentation practices. In my opinion, earlier support could have been sought from the NP/GP in relation to Mrs E’s pressure area, given that there were clear indications that her wound was not healing. This was particularly necessary in light of Mrs E’s history of diabetes, which is known to affect wound healing, and her high risk for developing pressure areas, as was noted during admission.
    
    
76. However, it does appear that, overall, Eileen Mary Age Care Limited provided regular and consistent pressure injury preventive care and gained appropriate support from the wound specialist and dietician services for Mrs E.
    
    
77. In my opinion, there are also opportunities for improvement with respect to the pain management practices. Although progress notes show that signs of pain were being monitored, this should have been assessed using a formal pain assessment tool, as is required by Eileen Mary Age Care Limited’s Pain Management Policy.
    
    

Mrs F

78. Dr G, GP at the local GP centre, complained about the care provided to Mrs F. Dr G is concerned about the standard of wound care provided to Mrs F and the lack of documentation with respect to the wound care in 2023 and 2024.
    
    
79. Mrs F, aged in her 80s at the time, was admitted to the care facility on 17 August 2017, initially for rest-home level care but was then transitioned to hospital-level care in February 2023. She had multiple comorbidities, including Paget’s disease[26] of the vulva, which required treatment with topical ointments. Eileen Mary Age Care Limited said that the Paget’s disease was not problematic for Mrs F until 2020, when her symptoms appeared to flare up. Eileen Mary Age Care Limited stated that Mrs F then had persistent ongoing issues with pain and rashes related to the Paget’s disease. Eileen Mary Age Care Limited also said that Mrs F had a temporary indwelling catheter to reduce irritation and pain around the genitalia associated with urinary incontinence. In addition, caregivers avoided using soap products on the genitalia and implemented a regular toileting schedule and other hygiene measures to minimise the risk of irritation and skin breakdown.
    
    
80. Mrs F’s LTCP records that she had a rash on her vulva. The LTCP instructs staff to monitor her skin integrity during personal cares and to report to a nurse any concerns such as vaginal/vulval redness, skin breaks, bruises, and pain. The LTCP also instructs staff to apply topical ointments to the affected area. A wound care plan and an STCP were not developed in relation to the Paget’s disease rash. Eileen Mary Age Care Limited said that as Paget’s disease is a long-term skin condition, a specific wound care plan was not required. Eileen Mary Age Care Limited’s Wound and Skin Care Management policy states that all wounds, including chronic wounds and skin treatments, are required to be documented in the clinical records.
    
    
81. Eileen Mary Age Care Limited said that the resident’s skin integrity is monitored in the general care reporting/handover documentation, and this is the accepted practice across the aged residential care sector. However, progress notes do not always record skin checks as having been completed every shift or what care had been provided in relation to the Paget’s disease rash.
    
    
82. Eileen Mary Age Care Limited said that, from 2023, Mrs F was reviewed by the GP/NP on at least 26 occasions for vaginal pain related to the Paget’s disease. On 17 May 2024, the GP/NP recorded: ‘[A nurse is] to check the area daily for skin breakdown and advise if [there is] change from redness to worsening skin.’ On 25 July 2024, the GP/NP recorded: ‘[Registered nurses are] to apply [topical treatments] NOT caregivers!!!’, suggesting that nurses may not have been providing oversight of the rash.
    
    
83. No STCP was commenced, and the progress notes do not record any assessments completed by nurses, as instructed by the GP/NP. Progress notes show that caregivers escalated issues relating to the rash to nurses but do not show the actions taken by nurses in response. Eileen Mary Age Care Limited stated that a HealthCERT surveillance audit identified a lack of information regarding the management and appearance of Mrs F’s rash and Paget’s disease in the progress notes. Eileen Mary Age Care Limited acknowledged that the documentation in Mrs F’s case was insufficient.
    
    
84. As noted above, Mrs F had ongoing issues with pain. The LTCP indicates that Mrs F wished to be pain free. Her medication prescription shows that she was receiving regular paracetamol and codeine (strong pain relief). The codeine was prescribed under the ‘as required’ section, but medication administration records show that she was receiving regular doses. Eileen Mary Age Care Limited said that staff relied on Mrs F to self-report her pain levels. No pain management plan was started to manage her ongoing pain. The medication administration records show that pain scores were calculated before pain relief was administered. The presence or absence of pain was recorded in the progress notes, but the efficacy of the pain relief was not always recorded, as acknowledged by Eileen Mary Age Care Limited. In addition, codeine is known to cause constipation. However, the clinical records do not show whether Mrs F’s bowels were monitored and whether she was experiencing constipation.
    
    

In-house clinical advice (Appendix E)

85. RN Ferreira noted the following departures from the accepted standards of care:

• • Standard of documentation in relation to wound/skin care with respect to vaginal rash — mild departures.
  • Standard of pain management — mild to moderate departure.
  • Standard of overall documentation — mild departure.

86. In addition to the above, RN Ferreira criticised the lack of documentation around the monitoring of CHF and weight recordings.
    
    

Decision – adverse comment

87. Having reviewed all the available information, I agree with RN Ferreira that there are several areas of concern in the care provided to Mrs F. I am concerned that Eileen Mary Age Care Limited did not consider that a wound care plan is required for chronic skin conditions. In my opinion, Mrs F’s known skin condition required ongoing monitoring and frequent intervention. This warranted a dedicated management plan and consistent oversight from a nurse.
    
    
88. While it is evident that care was occurring and that staff were responsive to Mrs F’s ongoing discomfort, I am concerned about the standard of documentation undertaken by staff with respect to the Paget’s disease and Mrs F’s pain levels. It is clear that Mrs F experienced regular episodes of discomfort, and it is my opinion that more thorough documentation of the characteristics of her symptoms would have better supported the assessments undertaken by clinicians at the local GP centre.

Response from providers

89. Eileen Mary Age Care Limited was provided with a full copy of the provisional report and given the opportunity to comment. It accepted the findings in the provisional report and extends its sincere apologies to the residents and families affected. It acknowledged the need for wound care plans for chronic skin conditions, documentation of dedicated management plans, and consistent oversight of residents by RNs.
    
    
90. Eileen Mary Age Care Limited said that recruiting experienced staff remains a persistent challenge and that this made the ability to provide a high standard of care more difficult at the time. Although it continues to support the development of clinical managers, sustaining leadership within complex care environments is also a challenge. Eileen Mary Age Care Limited said that these issues highlighted a need for sector-wide strategies to strengthen leadership capability and workforce resilience in aged care.
    
    
91. The new operator of the care facility was provided with a full copy of the provisional report and given the opportunity to comment. The new operator did not wish to make any comments as they were not the operator of the care facility at the time of the events.
    
    

Changes made

92. Eileen Mary Age Care Limited said that it has made the following changes since 13 November 2024:

• • Staff have undertaken education on wound assessment and management; pressure injury management; the role of the EPOA, including how they are activated; hydration and nutrition; the admission process; open disclosure; effective communication, including with families and external services; pain management; transferring residents to hospital; end-of-life care; and the use of emergency medication.
  • The handover process has been refined so that all wounds are mentioned during nursing handovers. Full handovers are also provided to the clinical manager each weekday, which allows the clinical manager to provide more support, guidance, and supervision to the nursing staff.
  • It purchased a phone so that photos can be taken of wounds and the information included in the clinical records.
  • It plans to provide education to staff on how to identify/observe resident breast abnormalities and how to palpate a breast to identify lumps and other medical issues.
  • It has reminded staff of the need to follow up with resident families and NPs/GPs when admission forms have not been completed.
  • It has reviewed its nutrition and hydration policy.
  • Admission agreements are now discussed with the resident and family on admission, and the care facility manager is responsible for this.
  • The acting operations manager has worked with the care facility manager and the clinical team to mentor and review nursing knowledge and understanding of safe practice and standards of documentation.
  • Staff are now checking and reporting on the appearance of genitalia in the progress notes.

93. Further, Eileen Mary Age Care Limited’s parent company has made the following changes in the context of its other operations since 13 November 2024:

• • Established a group care and clinical governance structure, including a dedicated support office and a group clinical and quality manager, to provide clinical oversight; mentoring; leadership; regular care facility checks; and internal auditing and adverse event, complaint, and incident reviews to ensure compliance with accepted standards.
  • The support office can now access the electronic clinical management systems remotely to provide real-time oversight to identify departures from best practice.
  • Appointed a dedicated human resources manager to oversee recruitment and staff onboarding and orientation processes.
  • Established an in-person clinical forum and ongoing monthly clinical meetings to discuss management of clinical care.
  • Implemented regular care facility manager meetings.
  • Appointed an experienced chief operating officer who is a registered nurse and has been tasked with driving safe, personalised, and individualised care.

94. Health NZ’s Ageing Well and Service Improvement team completed a review of the complaints received by HDC. This review resulted in several meetings with Eileen Mary Age Care Limited and the new operator to discuss and implement service improvements. Weekly reporting and regular meetings were scheduled with Health NZ to monitor progress on actions related to improving staff support, clinical leadership, and education
    
    
95. The new operator said it continues to make improvements at the care facility, including improving staffing levels, staff retention, the appointment of a clinical nurse leader, the provision of extensive education and training to staff, and the ongoing development of strong collaborative relationships with the community. The new operator noted that the care facility’s occupancy has increased over the last 10 months as community confidence in the care it provides has grown.
    
    
96. In addition, the new operator provided further correspondence from Health NZ, which stated that HealthCERT was reassured with the actions taken by the new operator.  The new operator has said that they will continue to work with staff on the completion of all corrective actions and will communicate with HDC and HealthCERT regarding any concerns.
    
    

Recommendations and follow-up actions

97. I acknowledge the changes undertaken by Eileen Mary Age Care Limited. In addition, I make the following recommendations to the new operator of the care facility:

1. 1. Undertake an audit of 10 deceased residents to determine whether an end-of-life care plan was established for the resident. A summary of the audit findings, including the corrective actions to be implemented, is to be provided to HDC within 18 months of the date of this report.
      
      
   2. Undertake an audit of 10 residents who are known to experience chronic or acute pain, to determine whether the care provided to the residents complied with its Pain Management Policy. A summary of the audit findings, including the corrective actions to be implemented, is to be provided to HDC within 18 months of the date of this report.
      
      
   3. Undertake an audit of the 15 most recent incidents relating to wounds in conjunction with the associated resident file to determine the degree of compliance with wound care against the new operator’s wound management policy. A summary of the findings with corrective actions to be implemented is to be provided to HDC within 18 months of the date of this report.
      
      
   4. Consider implementing weekly reviews of at-risk residents to ensure that appropriate clinical oversight of care is maintained, as suggested by RN Ferreira. Evidence of the weekly reviews being completed is to be provided to HDC within six months of the date of this report.
      
      
   5. Consider strengthening the resident admission process to ensure that health backgrounds, precautionary care requirements, and goals of care are clearly reflected in the care record where possible, as suggested by RN Ferreira. An updated copy of the Admission Policy and Procedures document is to be provided to HDC, along with a summary of the changes made, within three months of the date of this report.
      
      
   6. Following completion of recommendation 96e), the new operator is to undertake an audit of the 10 most recently admitted residents to determine the compliance against its resident admission process. A summary of the findings with corrective actions to be implemented is to be provided to HDC within six months of the date of this report.
      
      
   7. Establish regular meetings between the care facility management and GP/NP services to identify and address any concerns early, ensuring collaborative and timely resolution over any concerns. A summary of three meetings, including discussions held and any corrective actions to be implemented, is to be provided to HDC within six months of the date of this report.
      
      

98. An anonymised copy of this report (naming only Eileen Mary Age Care Limited, EMAC 1 Limited, and my clinical advisors) will be placed on the HDC website (www.hdc.org.nz) for educational purposes and forwarded to HealthCERT at the Ministry of Health | Manatū Hauora and Health New Zealand | Te Whatu Ora.
    
    
99. A copy of this report relating to the care provided to Ms B will be provided to the Coroner.

Nāku iti noa, nā

Rose Wall
Deputy Health and Disability Commissioner