An 85-year-old woman described smelling burning flesh after her rest home bed was pushed up against a heater, giving her second-degree burns.
Her family told the Health and Disability Commission they would be forever haunted by the description.
Oceania Care Company Limited (trading as Elmwood Village) has apologised in the latest Health and Disability Commissioner report after the bedbound woman needed a skin graft when her bed was left too close to a heater with no guard.
The woman's second-degree burn of her left leg subsequently became infected, and was not assessed physically or seen by a GP or senior registered nurse for 20 days.
The incident happened between April and May 2022 while the woman (identified as Mrs B in the report) was a resident.
Oceania said this was because the nurses did not identify the severity of the burn and therefore did not consider that a review was necessary at the time.
The report included a response from Oceania Care, which said it did not dispute any of the information gathered during the investigation and had made changes as a result.
"We accept that the specific issues with the standard of care provided to [Mrs B] are the result of poor adherence to policies and procedures by multiple staff, and inadequate systems in place at Elmwood. We take overall responsibility for the deficiencies in the care provided to. We accept that these are attributed to systemic issues that we are in the process of addressing," the Oceania statement said.
"[We are] deeply sorry that we did not provide [Mrs B] with an appropriate standard of care between April and May 2022 and that our communication with the family during this time and during our internal investigation was not satisfactory."
Ms A's granddaughter (known as A), said the event was unforgivable for the family.
The family said they would forever be haunted by the image of their grandmother describing the smell of her own burning flesh.
"It is unthinkable that the wound was not physically assessed by a senior nurse, GP, or nurse practitioner for 20 days. It is hurtful for us to confirm that no one thought her injury was significant enough to require immediate medical attention.
"Our grandmother was already in a fragile state and did not need to undergo an extreme skin graft surgery at her old age. We believe this injury contributed significantly towards her declining health.
"It took multiple requests before we were finally shown the true extent of her injury. This delay in transparency is, to us, clear evidence that the staff knew how bad the injury really was and were trying to downplay it."
Ms A said there had been profound cultural impacts as a result of the event and said the family regretted admitting their grandmother to Elmwood every day.
"In our culture, caring for elders ourselves is the norm. Placing our grandmother in a care home was a heartbreaking decision made out of necessity after her stroke. To now know she was neglected upon admission and burned while in their care — and left in pain for weeks — has caused indescribable pain to our family," A said.
"This was our grandmother — the woman who raised us, loved us unconditionally, and showed us endless kindness throughout our lives. She was the sweetest soul we have ever known, and even these words fail to capture how much she meant to us."
The Health and Disability Commissioner report said Mrs B had been admitted to Elmwood Village on April 20, 2022 following a stroke which caused her to have left-sided paralysis.
The HDC report said Mrs B's family could no longer care for her as their grandmother had become "bedbound" and needed full support with her care, including eating, drinking, showering and toileting, and full assistance to reposition herself in bed to prevent pressure injuries forming.
Two days after being admitted into Elmwood Village, the rest home was in lockdown due to a second wave of Covid-19, with residents' families unable to visit instead relying on phone calls for updates from staff. Oceania told HDC that at the time of Mrs B's injury, Elmwood was in a second Covid-19 lockdown with several staff off sick and other staff taking extra shifts.
On April 29, nine days after first being admitted, carers moved Mrs B's bed against a wall in her room so "not roll off the bed" during the night.
However, the HDC report claims the carers were unaware of the heater, which did not have a guard reinstalled due to recent renovations.
At 1.30am on April 29, 2022, a carer checked on Mrs B and noticed that her left leg had slipped down between the heater and the bed, and that she had sustained a large second-degree burn to her leg.
The HDC said while a registered nurse "examined the wound, provided first aid, dressed the wound, started a wound chart" and completed an incident form, there was no evidence that Mrs B's burn wound was submerged in water or that water was poured over the burn to cool the wound, and instead a dry dressing was placed over the wound.
On the morning of April 29, another Registered Nurse informed Mrs B's family about the burn. Mrs B's granddaughter (known as Ms A) told HDC that they were told that Mrs B had sustained a burn injury but that it was "minor" while maintenance staff replaced the guard rails on Mrs B's room heater.
On May 4, 2022 Mrs B complained of pain on multiple occasions but a pain chart was not commenced, although staff took a wound swab of Mrs B's burn injury, as the wound contained appeared infected.
Two days later on May 6, it was confirmed the injury was suffering from a Staphylococcus aureus infection and Mrs B was prescribed a seven-day course of oral antibiotics.
The family subsequently visited Mrs B and asked to speak with a staff member regarding the burn incident five days later. The family were assured an investigation was underway.
Later that month, on May 17, 2022 a family meeting was held with Mrs B's granddaughters and senior staff with the burn injury and investigation outcome discussed. Mrs B's granddaughters were shown a photo of the initial wound and the current wound and were noted to have been "shocked" at the large size of the injury.
Later that day, progress notes document that Mrs B's burn wound was assessed by GP Dr G and still appeared infected, as yellowish discharge was present. A referral to a plastic reconstructive service team was made.
Ms A told HDC that the family "pushed" for Mrs B to go to a hospital for treatment after a family meeting was held on May 20, 2022. Mrs B was taken to a public hospital a day later for wound debridement and grafting.
Mrs B was discharged from the hospital on May 31, 2022 and returned to Elmwood, with instructions provided on how to manage her wounds (graft wound and donor wound).
The commissioner said Oceania Care Company Limited breached Right 4(1) and Right 4(4) of the Code of Health and Disability Services Consumers' Rights.
"I find that Oceania Care Company Limited (trading as Elmwood Village) did not provide Mrs B with an appropriate standard of care in April to May 2022. I consider that the issues represent a pattern of poor care and non-compliance with policies, for which ultimately Oceania is responsible.
"Oceania is responsible for ensuring that all staff are aware of, and follow, its policies. Given that multiple staff failed to follow Oceania's policies, I consider this to be a systemic issue attributable to Oceania."
The commissioner said Oceania will be referred to the Director of Proceedings in accordance with section 45(2)(f) of the Health and Disability Commissioner Act 1994 for the purpose of deciding whether any proceedings should be taken.
Among the HDC's recommendations was for Oceania Care Company Limited to provide a written apology to Mrs B's family.
Ms A said the HDC report brought up an "overwhelming wave of pain and sadness" for what their grandmother experienced and said the family was devastated and furious "about the horrific negligence our grandmother suffered at Elmwood Village".
"It was not simply a failure in care — it was systemic, preventable harm that left [Mrs B] in pain, untreated, and completely dehumanised.
"The pandemic may have put pressure on operations, but it is not and will never be an excuse to abandon fundamental duties like ensuring a patient is safe in her bed. Our grandmother was left lying for hours with her skin pressed against a hot, unguarded heater, sustaining severe second-degree burns."
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