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Non-compliance with lifting and transfer policy and failure to report incident (07HDC16959)
Download Non-compliance with lifting and transfer policy and failure to report incident (07HDC16959) (PDF 150Kb)
(07HDC16959, 20 May
2008)
Rest home/hospital ~ Caregiver ~ Transfer ~ Hoist ~ Fracture
~ Incident report ~ Documentation ~ Standard of care ~ Adequacy of
quality care systems ~ Rights 4(1), 4(2), 4(5)
An 81-year-old woman was admitted to a rest home/hospital after
being assessed as requiring hospital level care. She was only
occasionally able to respond verbally.
One morning, a caregiver noticed that the woman had severe
bruising and swelling to her left arm. The caregiver reported this
to the registered nurses but no action was taken in relation to
this injury until three days later when another caregiver noticed
and reported the bruising to senior nursing staff. The facility's
general practitioner was asked to visit to examine the woman.
The GP saw the woman that afternoon and arranged for her to be
transferred to a private hospital for an X-ray, which confirmed
that the woman's arm was fractured. The manager immediately
commenced an investigation into the circumstances of the woman's
fracture. It was not until eight days later that the caregiver
admitted that she had dropped the woman from a lifting hoist.
It was found that by failing to use the correct hoist the
caregiver did not provide a service with reasonable care and skill.
In trying unsuccessfully to stand the patient alone to dress her,
she failed to follow the policy that such transfers are to be
conducted by two staff. She did not comply with relevant standards,
in breach of Rights 4(1) and 4(2). When she failed to report the
accident, she contravened the policy of her employer relating to
accident and incident reporting, and deprived the patient of the
chance to have her injuries attended to in a timely manner. As a
result, the patient suffered the pain of a fractured arm for four
days. These actions amounted to a breach of Rights 4(2) and
4(5).
The caregiver was not the only staff member who failed to follow
the facility's policies and procedures. Other care staff moved the
woman without a hoist and/or without assistance. Four different
nurses failed to adequately assess the woman when told about the
bruising. Workload was an issue.
It was found that the failure to follow policies and procedures
by so many staff demonstrated a culture of non-compliance, and an
environment that did not sufficiently support and assist staff to
do what was required of them. The rest home failed to provide
services with reasonable care and skill and therefore breached
Right 4(1).
The caregiver was referred to the Director of Proceedings, who
issued proceedings before the Human Rights Review Tribunal. The
matter proceeded by way of an agreed summary of facts in which the
caregiver admitted a number of key failings on her part. The
Tribunal made a declaration that the caregiver's actions were in
breach of Rights 4(1), 4(2), and 4(5).
Link to Human Rights Review Tribunal decision:
http://www.nzlii.org/nz/cases/NZHRRT/2009/1.html