A care home failed to properly look after a 70-year-old woman with dementia after other residents likely assaulted her, the healthcare watchdog found.
In a decision released this morning, the Health and Disability Commissioner found that service provider Ultimate Care Group (UCG) breached multiple rights while caring for the woman.
It comes after the woman’s son made a complaint about multiple “unexplained injuries” - which included bruising - the woman was receiving while in the home.
An independent investigation by UCG in 2019 found “little evidence that other residents [were] involved in any altercation” and said the woman's bruises were likely caused by falls.
It found that on multiple occasions, caregivers reported bruises in the woman’s progress notes but did not notify her son as the nurses had failed to enter it into UCG’s electronic incident and accident system.
The provider put in place a healthcare plan, which noted the woman “sustains bruises very easily just from constantly walking around”.
Unsatisfied with the internal report, the son arranged to move his mother to another home — and made further complaints that his mother was being physically abused.
In a response to the son, the provider said: “[UCG had] provided the best possible care for [the woman]”.
He also made a complaint to the DBH, who conducted their own audit into the woman’s treatment
In its own report, the DHB found the woman’s bruises were “likely to have been caused by a mix of probable unwitnessed physical assault by other residents, possible unwitnessed rough handling by a staff member, and possible self-harm by banging into objects”.
It said, however, the “most likely cause” of the woman’s injuries was physical abuse at the hands of residents.
It found that UCG did not respond to the woman’s injuries appropriately “or take action to ensure her safety at the care home”.
It said that staff responses to the investigation showed a “culture of acceptance of bruising, a lack of documentation according to policy, a reluctance to consider all possibilities as to why Ms B sustained so many bruises, and acceptance of violence between residents in the dementia unit”.
The audit concluded the woman had been “passively neglected” while being cared for by UGC.
In her decision, HDC aged care commissioner Carolyn Cooper found UCG breached four of the women’s rights.
These are the right to services of an appropriate standard provided in a manner that minimises harm and optimises quality of life, the right to services that comply with legal, professional, ethical, and other relevant standards, the right to the fair, simple, speedy, and efficient resolution of complaints and the right to complain.
“I acknowledge the distress caused to Ms B and her family. Ms B was a vulnerable consumer who relied on the staff to keep her safe and to report and address any concerns about her safety and wellbeing,” Cooper said.
“This did not occur, and as a result, Ms B experienced repeated injuries over a prolonged period, which may have been preventable if appropriate and timely safeguards had been implemented.
“This is unacceptable in any residential care setting, and especially in those providing dementia care.”
She recommended that UCG provide a written apology to the woman and her family, report missing clinical records for the woman to the Privacy Commissioner and use the case as a basis for more staff training on complaints management and the detection and reporting of abuse.
Since the incidents, UCG has implemented a number of changes at its facilities, reviewing its “information-related IT policies and procedures”.
It also updated its complaints education as well as policy, procedures and forms.
“A new organisational structure has been put in place, and new clinical roles have been created to focus on monitoring of resident e-files and giving real-time feedback to managers” Cooper said.
1News has contacted UCG for comment.
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