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Assessment, monitoring and evaluation of nutritional status and sacral pressure ulcer, and communication with family (10HDC01286)
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(10HDC01286, 18 November 2013)
Aged care provider ~ Clinical manager ~ Registered nurse ~
General practitioner ~ Systems issues ~ Clinical decisions ~
Communication ~ Staff training & supervision ~ Right
A 40-year-old woman was admitted to a care facility for people
with age-related illness, and young physically disabled people. Two
years prior, the woman had had a stroke and was left paralysed on
her left side, with urinary incontinence, seizure activity and
Staffing at the care facility included a registered nurse (RN)
Facility Manager, a RN Clinical Manager, RNs and enrolled nurses,
and care assistants. During her admission, the woman received care
and treatment related to a number of health issues, including
neurological assessments related to seizure activity, behavioural
and psychiatric assessments for low mood, and dietitian input for
Five and a half years after her admission, the woman's pressure
ulcer risk was evaluated and found to be high. However, no
preventative measures were taken in response to the risk. Four
months after this assessment, the woman's condition began to
deteriorate. She reported nausea, at times she was reluctant to eat
and drink, and she was noted to have a low mood. Over the next
three months, the woman developed sacral pressure ulcers which did
not heal and which became infected and necrotic. The woman was
admitted to a large public hospital with a high fever, where she
was noted to be hypotensive and in renal failure. The woman was
provided with palliative care, and she died of sepsis secondary to
a sacral pressure ulcer two days after her admission.
The first of the two Clinical Managers employed at the time of
these events did not ensure that a quality service was provided to
the woman. In particular, the first Clinical Manager failed to
adequately manage the woman's pressure ulcer risk, failed to ensure
appropriate care planning when she developed a pressure ulcer, and
failed to ensure that there was adequate monitoring of her
deteriorating health. The second of the two Clinical Managers
employed at the time of these events did not ensure that the
woman's deteriorating condition was adequately monitored and
responded to in the two months leading up to the woman's hospital
admission. The Clinical Managers breached Right 4(1).
The owner/operator of the facility was vicariously liable for
the clinical failures of its staff and breached Right 4(1).
Additionally, the owner/operator failed to ensure that staff were
adequately oriented to, and supported in, their roles, and also
breached Right 4(1) in this respect. Adverse comment was made about
the owner/operator's role in ensuring adequate staffing, its
suboptimal documentation, and its role in ensuring the availability
of adequate equipment.
It was not clear whether or not the Facility Manager fulfilled
her responsibility to ensure that adequate equipment was available.
However, in respect of the clinical care provided to the woman, the
Facility Manager was not found to have breached the Code.
Adverse comment was made about the care provided by the
GP, who acknowledged that he should have referred the woman
earlier for aggressive pressure ulcer treatment.