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Failure to provide appropriate respite care in rest home (15HDC00420)
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(15HDC00420, 15 June
Rest home and hospital ~ Registered nurse ~ Respite care ~
Metastatic prostate cancer ~ Urethral catheter ~ Admission ~ Care
plan ~ Monitoring ~ Standard of care ~ Right 4(1)
A 77-year-old man with castrate resistant metastatic prostate
cancer was admitted to a rest home for one week of respite care
over a holiday period. The man had a long-term, large sized,
urethral catheter in situ.
Prior to admission, staff from Needs Assessment and Support
Coordination gave information to the rest home that set out that
the man had ongoing issues with his catheter blocking, which would
require hospital-level care, and that he had a large bladder mass
severely obstructing urine flow.
The man was previously known to the rest home, having spent 11
nights there for respite care several months earlier. A short-stay
nursing assessment and support plan had been completed for the man
on his previous admission, but this was not updated on his next
admission, nor was a specific catheter care plan initiated.
On the first night at the rest home, the man complained of pain
related to urinating. His catheter had not drained any urine and a
nurse performed bladder irrigation, which expelled blood clots and
the catheter began draining well.
During the night, the man continued to complain of pain and was
given pain relief. At 4.45am, caregivers reported to a nurse that
the man's urine was bypassing the catheter and was "bleeding a
little". The nurse noted that no urine had drained into the
catheter bag since 1am. She attempted bladder irrigation without
success, and then removed the man's catheter but did not
recatheterise him. There was no correct sized catheter in stock at
the rest home.
The man vomited the next morning. The nurse on shift recorded
that she witnessed him passing a "reasonable" amount of urine. At
4pm a nurse inserted a correct sized catheter, which the man's
daughter had supplied. A small amount of urine passed. The man
continued to pass low levels of urine. He refused dinner and drank
minimal fluids. No formal fluid balance monitoring occurred. The
man experienced abdominal pain overnight. He was provided pain
relief and bladder irrigation, which drained a small amount of
On the morning of his third day at the rest home, the man
vomited on several occasions. His low urine output continued. That
afternoon the man's daughter, who had been expressing concerns
about her father's deterioration, took her father to hospital and
he died in hospital several days later.
It was held that the rest home breached Right 4(1) as it failed
in its duty to ensure that the man received services of an
appropriate standard while at the rest home, in the following
- Care management plans were not updated on admission to reflect
the man's current clinical presentation, nor were plans established
to manage the regular and known problem of the man's catheter
- Bladder irrigation was performed several times without first
seeking medical advice, as required by rest home policy, and
without documenting the amount of saline fluid used.
- The man's catheter was removed without seeking medical advice,
and he was not recatheterised promptly.
- No formal fluid balance chart was commenced, and the monitoring
of the man's fluid balance was infrequent and inadequate.
- Concerns about the man's condition were not escalated to the
on-call manager by nursing staff, and they did not seek medical
It was recommended that the rest home provide staff with further
education and training on several topics, including admission
planning, monitoring of bladder irrigation, catheter removal and
fluid balance monitoring. The rest home was asked to use this case
for staff education at other facilities, and to apologise to the