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Monitoring of cellulitis by registered nurses in an aged care facility (05HDC07285)

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(05HDC07285, 13 September 2006)

Registered nurses ~ Standards of care ~ Adequacy of quality care systems ~ Rights 4(1), 4(2)

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.