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Monitoring of cellulitis by registered nurses in an aged care facility (05HDC07285)
Download Monitoring of cellulitis by registered nurses in an aged care facility (05HDC07285) (PDF 11Kb)
(05HDC07285, 13 September 2006)
Registered nurses ~ Standards of
care ~ Adequacy of quality care systems ~ Rights 4(1),
An elderly patient in a private aged
care facility sustained a skin tear to her right arm. A week later
she was noted to be unwell and thought to have a urinary tract
infection. Orders were given to obtain a urine specimen and
commence her on routine temperature recordings. Over the following
three days her temperature was taken irregularly. Clinical records
show that her temperature ranged between 36.2°C and 39°C. Her arm
was redressed as required, but there is no record that the urine
specimen was obtained.
Four days later the woman's arm was
noted to be red and swollen. Early the next morning, caregiving
staff reported to a registered nurse that the woman's breathing
pattern had changed. The nurse stated that she was unaware of this
and did not report a change in the woman's condition at handover.
When another registered nurse saw the woman two hours later she
found her to be severely ill. Her right arm was grossly swollen,
and black and purple in colour. She was transferred to a public
hospital where she was diagnosed as suffering septicaemia. She died
the following day.
All registered nurses involved in
the woman's care, and the aged care facility, were found to have
breached Rights 4(1) and 4(2).
Two of the registered nurses were
referred to the Director of Proceedings, who considered the matter
and decided not to issue any proceedings. The failures of the
nurses gave rise to concern about their practice and public safety
and, accordingly, the Director referred them both to the Nursing
Council for competence review.
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