A rest home has been found in breach of the code for failing to investigate and think critically, leading to the death of a resident who had developed cellulitis in her legs.
The woman, aged in her late 90s, was moved to the hospital wing of an aged residential care facility last year.
She had a number of complex health issues, including asthma, heart disease, osteoarthritis, a shoulder injury and suffered from chronic pain, hypertension and was at risk of falling, Health and Disability Commissioner Rose Wall said in her report, released today.
The woman’s initial care plan made special note of her fall risk and that she required assistance for using the toilet and transfer to a wheelchair, which she preferred to use due to pain in her legs. Special note was also made in the plan to respond to any changes in her mood or behaviour over the next six months.
Over the course of the next few months the woman became increasingly frail with days of restlessness, low mood and confusion. Nurses noted that she was eating and drinking well over the period, so did not feel the need to investigate the woman’s distress any further.
After her pain levels increased and her legs became red and hot to touch, the doctor diagnosed her with cellulitis, a common yet potentially serious bacterial skin infection. She was admitted to hospital for intravenous antibiotics. However, she failed to respond to the treatment, and a decision was made with the woman’s family and medical staff to stop active treatment, and palliative care begun.
The woman returned to the rest home, where she died five days later.
"The rest home had a duty to provide the woman with reasonable care and skill, which included being responsible for the actions of its staff at the rest home," Wall said.
"The woman’s medical history indicated she was likely to experience a progressive decline. In particular, she was noted to be at risk of having a decline in her mood, and to experience high levels of pain in her legs.
"In light of this, the various nursing staff involved in her care should have been alert to a deterioration in her condition, and intervened as required, including seeking medical attention when warranted. Staff should have ensured the woman was well supported in an environment conducive to keeping her calm and comfortable."
The Commissioner made a number of recommendations, including that the rest home provide a written apology to the family for deficiencies in the woman’s care outlined in the report, and that the nursing staff be given training on the new Assessment and Management of the Acutely Unwell Resident policy.
A recommendation was also made for the rest home to provide all staff with training on the identification and management of infection, assessment and management of general decline in the elderly; informed consent; supported decision-making; EOPAs; palliative care; and the implementation of the Last Days of Life policy care planning throughout the rest home company’s facilities.
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