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Care of elderly man in rest home (12HDC01420)
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Rest home ~ Registered nurse ~ Influenza ~ End of life care
~ Communication ~ Morphine ~ Controlled drug ~ Rights 4(5), 6(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
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
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
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
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.