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Management of rest home resident’s pain and falls (09HDC00987)

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(09HDC00987, 31 March 2010)

Rest home ~ Registered nurse ~ Manager ~ Standard of care ~ Management of pain ~ Management of falls ~ Documentation ~ Clinical governance and quality systems ~ Rights 4(1), 4(2), 4(4)

The family of an 82-year-old woman complained about the standard of care she received at a rest home. The woman suffered four falls over a period of 14 months. After the final fall she was assessed by a caregiver and no injuries were detected. At the family's insistence a doctor was called in to examine the woman. Caregivers reported that she was able to mobilise and the doctor did not get her out of bed. No serious injuries were detected and the woman continued to be encouraged to walk despite being in a lot of pain. Five days later her ankle was noted to be swollen and she was taken to the local medical centre where it was X-rayed. She was diagnosed with a fractured right ankle and a fractured right hip, which appeared to have occurred several weeks earlier.

The woman was also suffering from pre-existing chronic back and chest pain. During the investigation, concerns were raised about the management of this pain.

It was held that the rest home had appointed staff with insufficient experience and skill without providing adequate support and guidance to ensure safe practice, and in accordance with relevant standards and, accordingly, it breached Rights 4(1), 4(2), and 4(4). 

The registered nurse was found to have failed to provide adequate follow-up care after the woman's falls, and to have taken insufficient steps to reduce the risk of further falls occurring. The nurse was also found to have provided inadequate care in the assessment and management of the woman's ongoing back and chest pain. Accordingly, she breached Rights 4(1) and 4(2).

It was also held that the rest home's manager breached Rights 4(2) and 4(4) for failing to oversee the delivery of services and to support staff adequately.

The rest home was referred to the Director of Proceedings.