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Monitoring of deteriorating condition of respite care dementia patient in an aged care facility (07HDC17647)

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(07HDC17647, 5 December 2008)

Aged care facility ~ Registered nurse ~ Clinical manager ~ Catheter ~ Dental plate ~ Fall ~ Standards of care ~ Documentation ~ Communication ~ Rights 4(1), 4(2)

A 90-year-old man who suffered from increasing dementia was admitted to an aged care facility for urgent respite care. In the nine days he was at the facility his condition deteriorated. On day three he pulled out his urinary drainage catheter and, four days later, he fell when left unattended in the shower. The day after the fall the man's family insisted that he have an X-ray because he had a sore throat and his partial dental plate was missing. The X-ray, taken the following day, showed that he had swallowed his dental plate. He was transferred to a public hospital, where the denture was removed under general anaesthetic.

It was held that the Clinical Manager should have been more vigilant in addressing documentation standards and care planning, and providing direction to staff. She did not provide the necessary clinical oversight required to ensure the man received services with reasonable care and skill, and breached Right 4(1).

The facility was new with a new clinical manager and staff, and monitoring of documentation was particularly important in this early stage, as was careful oversight of staff. The facility needed to ensure that such a process was in place and being carried out. It was held that the facility did not have adequate systems in place to prevent the Clinical Manager from breaching the Code, and thus were vicariously liable for her breach of Right 4(1). The service the man received when left in the bathroom was neither appropriate nor safe. By allowing a care assistant with insufficient skill or experience to have responsibility for the man, the facility breached Right 4(2).