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Care provided to elderly woman (11HDC00883)
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Aged care facility ~ Facility manager ~ Nurse manager ~
Registered nurse ~ Standard of care ~ Assessment and monitoring ~
Care planning ~ Documentation ~ Communication ~ Dignity ~ Rights 3,
4(1), 4(2), 4(5)
An 86-year-old woman was admitted to a rest home following
an admission to hospital for treatment of a scalp laceration
following a fall.
On admission, a care plan and nursing assessment were completed.
The care plan did not record how to manage the woman's diabetes,
dietary needs, prolapses, dementia and swallowing difficulties. The
woman's care plan was not kept updated.
During her admission, the woman had a number of changes to her
condition, including a suspected mini stroke, a number of falls,
swallowing difficulties and rapid weight loss. The woman's changing
condition was not adequately monitored, assessed, managed or
documented by the rest home's staff, and her personal care and
hygiene were not maintained to an acceptable standard. The rest
home's staff also failed, on occasion, to complete incident forms
or follow up incidents adequately.
The woman was transferred to a different rest home at the
request of her daughters. A few days after her transfer, the woman
was admitted to a public hospital. Investigations at the public
hospital indicated that the woman was hypothermic, and had
urosepsis and acute renal failure secondary to infection. She died
a short time later.
The nurse manager breached Right 4(1) for providing suboptimal
care to the woman with regard to care planning, incident reporting,
and her monitoring, assessment, documentation and management of the
woman's changing condition. The nurse manager also breached Right
4(2) for failing to comply with professional standards regarding
documentation, and Right 3 for leaving the woman for an
unreasonable length of time soiled or wet from urine, which showed
a lack of respect for her dignity. The nurse manager was referred
to the Director of Proceedings.
The facility manager had overall responsibility for ensuring a
quality service was provided to the woman. The facility manager did
not provide care to the woman with reasonable care and skill by
failing to ensure that the rest home's staff completed incident
forms and followed up incidents adequately. The facility manager
also did not ensure that the woman's care plans were completed
adequately and remained updated when her condition changed, and did
not ensure that the woman's clinical record and documentation were
kept up to date. For these reasons, the facility manager breached
The rest home breached Right 4(1) because it failed in its
responsibility to ensure that staff complied with policies and
provided services of an appropriate standard to the woman. The rest
home also breached Right 4(2) because its documentation was
suboptimal. The rest home also breached Right 4(5) for failing to
ensure that its staff communicated effectively with one another and
with other health professionals to ensure that the woman received
quality and continuity of services.
The Director of Proceedings decided not to institute proceedings
in this case.