A woman in her 90s died after she fell twice in one day at a retirement village.
The incident was detailed in a report released today by the Aged Care Commissioner Carolyn Cooper.
Cooper said the woman was a resident at a care home owned and operated by Chatswood Lifecare Limited. She suffered several falls, including two in one day in 2020.
She said as part of the woman's care plan made by the home, she was able to take herself to the toilet but staff were to ensure a walking frame was within reach and respond to the sensor mat or call bell quickly.
"On the day the woman had two falls, following the first fall a nurse created a short-term care plan, which noted that the woman should be supervised at all times when she was moving, her walking frame kept within reach, and her call bell responded to promptly.
"It is unclear whether the plan was handed over to the caregiver.
"The second fall occurred when the woman was briefly left on the toilet by a caregiver while the caregiver resumed the medication round to other residents.
"The fall resulted in the woman being admitted to hospital with a fractured hip and wrist. She was placed on a palliative care pathway and, sadly, she died a few days later," Cooper said.
The care home told HDC that its management team were "disappointed" the carer chose to continue with a medication round after assisting the woman to the toilet, rather than wait for her to finish in the toilet.
She said Chatswood Lifecare Ltd failed to provide services to the woman with reasonable care and skill.
The caregiver apologised to the woman's family for the criticisms in Cooper's report.
Cooper also recommended Chatswood Lifecare Limited also apologise in writing to the woman's family, review its process for handover to ensure that incoming staff are informed of resident issues, and put in place a system to provide support for caregivers in the rest-home wing during medication rounds.
She said Chatswood Lifecare Limited have since completed this.
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