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Care of elderly man in rest home (12HDC01420)

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(12HDC01420, 24 June 2015)

Rest home ~ Registered nurse ~ Influenza ~ End of life care ~ Communication ~ Morphine ~ Controlled drug ~ Rights 4(5), 6(1), 7(1)

A 96-year-old man, resident at a rest home, was diagnosed with influenza during an outbreak of influenza. The man's GP prescribed him oral amoxicillin for 7 days.

Approximately two days later the Clinical Manager (CM) went on sick leave with influenza and did not return to the rest home for approximately five days. As the CM was the only registered nurse on staff at this time, while she was on sick leave there were no registered nurses on site. However, the CM remained available by telephone contact, and continued to provide clinical advice to the Operations Manager (OM) at the rest home.

Three days after being diagnosed with influenza the man's condition deteriorated. The man's GP visited him and did not consider him to be terminally ill at that stage.

At 11.00am, four days after the man was diagnosed with influenza, the OM contacted the weekend duty doctor and told the doctor that the man was receiving "end of life care", was in pain and agitated and needed medication, and that he was having trouble swallowing tablets. The duty doctor advised the OM over the telephone to administer the man with 5ml of liquid morphine every four hours to decrease his discomfort. The duty doctor and the OM agreed that morphine elixir left over from another patient could be administered to the man.

The same day, the man was administered morphine on at least three occasions, however, this was not always documented appropriately. The rest home staff did not administer the man any further amoxicillin, despite his prescription being for another three days.

Five days after being diagnosed with influenza, the man was administered morphine on at least six occasions. At around 9.25pm, the duty doctor visited the man who was now unresponsive. The man's family, who was at the rest home, expressed concerns to the duty doctor that they were unaware that the man was receiving end-of-life care. The duty doctor checked the man's notes and found that there was no record of a decision to commence end-of-life care for him. The duty doctor decided to continue administering morphine to him every six hours to assist with his comfort. The man's condition continued to deteriorate, and he died a short time later. 

It was held that the rest home did not have in place appropriate systems to ensure that adequate cover would be available in the event that the only registered nurse on staff was unavailable. This failure led to poor communication between providers caring for the man and decisions being made about his care and treatment, without him being clinically assessed appropriately. Accordingly, the rest home failed to ensure that the man was provided continuity of services, in breach of Right 4(5).

The rest home staff failed to ensure that the man received relevant information regarding his condition and failed to obtain the man's informed consent to the commencement of morphine and withdrawal of amoxicillin. Accordingly, the rest home breached Rights 6(1) and 7(1).

Adverse comment was made about the rest home with regard to the following matters:

a)      The failure to record the administration of morphine adequately, in accordance with controlled drugs regulations.

b)      Its Medication Administration Policy not being in line with Ministry of Health (MOH) Guidelines with regard to requiring a registered nurse to be available to assess and monitor a patient who is administered a controlled drug for the first time.

c)      The administration to the man of morphine that was not prescribed for him.

d)      The lack of comprehensive documentation of discussions between the CM and rest home staff.

Adverse comment was made about the OM regarding her advice to the duty doctor that the man was on end-of-life care. The man had not been assessed as clinically appropriate for end-of-life care, and no discussion had taken place with him with regard to end-of-life care. The OM's communication with the duty doctor in this respect was inappropriate, and affected the quality and continuity of the man's care.

Adverse comment was made about the CM regarding having placed herself in an inappropriate position of retaining responsibility for patients while she was on sick leave.

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