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Change in administration of feeding regime without consultation (02HDC08819)

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(02HDC08819, 30 March 2005)

Rest home ~ Registered nurse ~ General practitioner ~ Dietitian ~ Assessment ~ Monitoring ~ Team care ~ Communication ~ Documentation ~ Systems audit ~ Standard of care ~ Professional, ethical, and legal standards ~ Contravention section 19(1) Medicines Act ~ Vicarious liability ~ Rights 4(1), 4(2), 4(5)

An 82-year-old rest home resident, with a complex medical history, was dependent for all his daily care. When he was hospitalised suffering from difficulty in swallowing, specialists, in consultation with the man's family, decided to insert a feeding tube through his abdominal wall to his stomach, so that he could receive nutritional supplements and fluids without needing to swallow. A hospital dietitian established a feeding programme for the man, based on 2,000ml of Jevity, a specialised complete liquid feed formula. An application for authority was made to Pharmac for the supply, and re-prescriptions were signed off by a GP on a monthly basis if there was no change to the regime. The minimum daily amount of Jevity a person requires in order to receive nutritional benefit is 1,321ml.

The hospital dietitian provided the rest home with written instructions, which included monitoring the man's weight on a weekly basis and undertaking regular assessments. The dietitian was to be informed of any changes. The rest home's registered nurse and visiting GP were required to provide oversight and refer back to the dietitian if the man began to lose weight or if assessments produced subclinical results.

Four months later, the man was hospitalised with persistent incontinence. To try to remedy the incontinence and intolerance, a second hospital dietitian reduced the Jevity intake to 1,500ml. Neither regime was followed up or reviewed by a private dietitian or a hospital. Two months later, without consultation, the registered nurse further reduced the man's daily intake to 1,000ml. In doing so, the nurse contravened a standing order and breached section 19(1) of the Medicines Act. With the reduced intake, the man steadily lost weight over the following 18 months. Weekly weighing was not undertaken as required, and the man's progress on the diet was not monitored. Documentation was poor.

It was held that a registered nurse exercising reasonable care and skill would not have reduced the intake and would have sought further advice, amounting to breaches of Rights 4(1), 4(2) and 4(5). Patients with complex medical presentations need to be effectively monitored and regularly reviewed.

It was also held that the rest home breached Right 4(2) in failing to audit documentation and residents' progress.

Following up with blood tests, and questioning the re-prescriptions over time would have been sensible courses of action, but the GP's failure to do so did not amount to a breach. A team care approach was critical to effective management of care, and the GP relied on what nursing staff told him.

The nurse was referred to the Director of Proceedings, who issued proceedings before the Health Practitioners Disciplinary Tribunal. A charge of professional misconduct was upheld. The nurse was censured and ordered to pay costs.

Link to Health Practitioners Disciplinary Tribunal decision:

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