A woman in her 90s died after falling over while two aged care workers were helping her walk to the bathroom — despite her care plan stating she was "not to be walked".
A recent decision by the Health and Disability Commissioner has found Invercargill rest home Calvary breached the woman's rights by "failing to provide services with reasonable care and skill".
At the time of the incident, the woman — who had been a resident at Calvary since 2015 — was receiving hospital-level care.
She was being treated for multiple illnesses, including osteoarthritis of the knees, atrial fibrillation, congestive heart failure, venous insufficiency, and hypertension and had a pacemaker for bradycardia.
In the years leading up to the accident, the woman had suffered a middle cerebral artery stroke, a possible myocardial infarction and a hiatus hernia.
She had also undergone a knee replacement, surgical repair of a femoral shaft fracture with internal fixation, and a surgical repair of a fractured femur neck in 2016.
Because of this, the woman's mobility was significantly limited, and in 2018, rest home staff noted it was continuing to worsen.
She needed two staff to hold her up to move short distances while she held a high gutter frame. To go further, she used a wheelchair.
Eventually, the rest home changed her care plan as walking had become "too fatiguing".
It offered several alternatives to walking, which included using a sling hoist and mobility belt.
However, a chart above the woman's bed, covering how staff should move her, wasn't updated to specify that she couldn't walk.
A staff member at Calvary said the advice was handed over verbally at a meeting.
One day, while being walked by two carers, the woman collapsed onto her knees. She was lowered to the floor, and staff rang the emergency bell.
The next day, the woman started complaining about a "strong pain in [her] legs", giving a pain score of 10/10. The HDC report described her breathing as "shallow and slow".
The woman was taken to hospital, where doctors found she had suffered a left proximal femur fracture.
An orthopaedic review found she was unfit for surgery, and she was admitted to palliative care.
The woman died the next day, with a coroner's report attributing her death to "bronchopneumonia subsequent to a fall".
Aged Care Commissioner Carolyn Cooper found the rest home's coordination around the woman's care was "inadequate".
"The physiotherapist documented the woman's mobility requirements appropriately and in a timely manner in the clinical records, but I am critical that the oncoming staff did not review the clinical records to identify any changes in the woman's care plan," Cooper said.
"In my view, the overall coordination of the woman's care between staff members at Calvary in relation to her mobility was inadequate."
She said the rest home's documentation oversights "indicate a pattern of poor documentation at Calvary", calling it "concerning".
The provider has since conducted an internal investigation and has implemented a "traffic light system" to make sure a patient's mobility requirements were explained clearly above patients' beds.
Cooper recommended Calvary provide a written apology to the woman's family and provide better education to staff on handovers and coordination of care.
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