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Standard of care of pressure sore (06HDC00079)

Download Standard of care of pressure sore (06HDC00079) (PDF 33Kb)

(06HDC00079, 30 November 2007)

Rest home ~ Hospital ~ General practitioner ~ Care manager ~ Registered nurse ~ Pressure sore ~ Nutrition ~ Medication ~ Documentation ~ Standard of care ~ Right 4(1)

An 89-year-old woman suffered a severe stroke and after public hospital care was transferred to a rest home). After her stroke, the woman was left with a little overall movement and limited control of her upper body. She had a known risk of sacral pressures sores and required feeding. The rest home's general practitioner assessed her twice during her stay. During a six-week period she developed a necrotic and infected bed sore which required plastic surgery and treatment. She also lost a significant amount of weight.

It was held that it was the responsibility of the rest home and the care manager to ensure the woman was appropriately assessed and managed. The pressure sore deteriorated during the time when the care manager was on leave, and was primarily the result of inadequate care provided by the registered nurses, and inadequate systems of care within the rest home. Despite the involvement of many different staff, there was a significant failure to respond to the woman's deteriorating pressure area and her weight loss. There was no indication that the registered nurses were appropriately supervised in the care manager's absence by management. In these circumstances both the care manager and the rest home failed to provide an appropriate standard of care and breached Right 4(1).

It was also held that the general practitioner did not provide an adequate standard of care during his assessments, and was reactive when a proactive approach was required. The general practitioner therefore breached Right 4(1).



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