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Rest home admission assessment and care (10HDC00308)
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(10HDC00308, 29 June
Aged care facility ~ Clinical services manager ~ Registered
nurse ~ Admission assessment ~ Hospital-level care ~ Documentation
~ Rights 4(1), 4(2)
The family of a 93-year-old man complained about the care
provided to their father when he was transferred from public
hospital care to an aged care facility.
The family contacted the facility's Clinical Services Manager
(CSM), a registered nurse, to discuss room availability and arrange
a viewing of a studio unit. The CSM formed the impression from
discussions with the family that their father had a reasonable
degree of independence.
The man underwent a geriatrician review and a support needs
assessment which identified that he required hospital-level care.
The assessment was faxed to the aged care facility. The studio unit
previously selected was not suitable, as hospital level-care could
not be delivered in that part of the facility. The CSM contacted
the family to arrange for their father to use a rest home room
until a hospital-level bed was available, but did not discuss the
arrangement with the hospital.
The man was transferred to the aged care facility. The admission
documentation and assessment completed by the admitting registered
nurse (RN) lacked sufficient detail and did not reflect the man's
care needs in relation to suprapubic catheter management, ulcer
care and urinalysis.
The room provided was in an out-of-the-way location and not
readily accessible by staff. The care provided by facility staff
over the next week was substandard. The concerns raised by family
members were not fully documented or acted upon. The GP was not
called. The man became very unwell and was transferred back to the
public hospital. Sadly, he died that evening. The cause of his
death was suspected to be sepsis. Subsequent complaints about their
father's care while resident in the facility which were made by the
family were poorly handled by the facility.
It was held that the CSM exercised poor skill and judgement in
admitting the man to a rest home bed in the knowledge that he
required hospital-level care, without making adequate arrangements
to ensure he received the level of care he required. She failed to
adequately oversee the provision of care delivered by other staff.
By failing to ensure the man received services of an appropriate
standard, she breached Right 4(1) and, by failing to maintain
adequate documentation, breached Right 4(2).
The admitting RN failed to adequately document the admission.
Admission records did not give clear information and direction to
other staff regarding the man's care needs and this affected the
continuity and quality of his subsequent care. She failed to comply
with the relevant standards and breached Right 4(2). The admitting
RN also failed to adequately assess the man or evaluate his
condition. She failed to provide services with reasonable care and
skill and breached Right 4(1).
It was also held that the facility's owners did not sufficiently
support or provide oversight of senior staff and did not ensure
that the man was provided with services with reasonable care and
skill, and therefore breached Right 4(1).