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Standard of care in dementia unit (08HDC17105)

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(08HDC17105, 26 August 2009)

Aged care facility ~ Registered nurse ~ Care manager ~ Dementia care ~ Standard of care ~ Informed consent ~ Nutrition ~ Medication ~ Response to family concerns ~ Behaviour management ~ Enduring power of attorney ~ Co-operation among providers ~ Clinical governance and quality systems ~ Vicarious liability ~ Rights 4(1), 4(3), 4(4)

It is a fundamental requirement that a dementia unit is able to provide appropriate care to dementia patients and to promptly recognise when the unit is no longer able to do so. 

The family of an elderly woman complained about the care she received in the dementia unit of an aged care facility. They had  become concerned about her physical, mental and emotional condition and made a number of complaints to the management. The woman was at times aggressive and unco-operative and there were difficulties getting her to eat and take her medication, attending to her personal hygiene, and cleaning her room. After the woman's condition and behaviour deteriorated further, a consultant psychiatrist assessed her and noted that she had not had a shower in over 12 months and was taking only about 75% of her prescribed antipsychotic medication. The woman was subsequently transferred to a psychogeriatric ward at a public hospital under the Mental Health (Compulsory Assessment and Treatment) Act 1992 where she was quickly able to be successfully medicated and showered and the family reported that "her dignity was restored".

It was found that the facility manager, a registered nurse, had needed to respond more quickly and do more to satisfy herself that the facility for which she was responsible, and its staff, were able to provide the woman with quality care. The family's concerns were longstanding and well documented, as were the growing difficulties for staff in managing the woman's care. The facility manager did not provide the elderly woman with a service consistent with her needs, and that minimised harm and optimised her quality of life, and therefore breached Rights 4(3) and 4(4).

The care manager, also a registered nurse, was responsible for the oversight of care provided to residents and patients, as well as orientation of new staff, in-service training, and infection control and monitoring of accidents and incidents. She had overall responsibility for the woman's clinical care. She should have recognised sooner that the facility was not able to provide the specialised level of care the woman required. Although various antipsychotic and sedation regimes were trialled, they had a limited effect in controlling her behaviour. The care manager should have advocated for the woman to be transferred to a specialised unit much earlier than was done. When behavioural issues arose, it was her responsibility to ensure that all reasonable strategies had been tried to enable appropriate clinical care to be provided. For these reasons she breached Right 4(1).

Dementia units care for mentally impaired residents. Therefore senior staff must also know the requirements of the Protection of Personal and Property Rights Act 1988, particularly in relation to an enduring power of attorney (EPOA).

Two daughters were recorded as having EPOA for their mother, when only one is allowed. All four daughters were involved in their mother's care and, at times, expressed differing views on what should be done. This is not unusual in aged care. While it can be difficult to manage, rest homes and dementia units need clear strategies for dealing with it. In this case, the care manager did not take appropriate steps to manage the situation. It was held that the facility did not provide services with reasonable care and skill and that were consistent with the woman's needs and minimised potential harm and optimised the quality of her life, and breached Rights 4(3) and 4(4). The facility was also found vicariously liable for the registered nurses' breaches of the Code.