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Wound care at rest home (12HDC01286)
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Rest home ~ Clinical manager ~ Facility manager ~ Wound care
~ Documentation ~ Rights 4(1), 4(2)
A 90-year-old woman was a resident at a rest home facility that
also provided hospital-level care. The woman had a skin cancer
lesion removed from her lower left leg at a public hospital (the
hospital) and was subsequently discharged back to the rest home the
same day. The discharge summary stated that the woman should stay
in the hospital wing of the rest home however the woman remained in
her room in the resident's wing, as there were no available beds in
the hospital wing. A new care plan was not implemented when the
woman returned to the rest home.
Over the next 12 days, the woman continued to have follow-up at
the hospital's outpatient plastics clinic with regard to her wound
care. Her wound care was then undertaken at the rest home.
Approximately four weeks following surgery, a swab taken from
the woman's wound indicated an infection, and the woman's general
practitioner (GP) prescribed antibiotics for her. There is no
record that either the woman or her daughter were informed that the
woman had an infection.
Approximately two months following her surgery, the woman's
daughter found the woman in her room in a confused and distressed
state. The facility manager reviewed the woman; however there is no
record of that assessment. The GP visited the rest home that
afternoon but he did not review the woman.
The following morning the woman was again confused and
disorientated, and had slurred speech and visible right-sided
drooping of her mouth. The facility manager assessed the woman and
considered that she had had a stroke. The GP assessed the woman a
few hours later and arranged her transfer to the hospital. The
medical team at the hospital concluded that the woman had
overwhelming sepsis and pneumonia (not related to the infection
previously discovered in the woman's wound). The woman died one
week following admission to the hospital.
It was held that the rest home's documentation of the woman's
care and treatment did not meet the New Zealand Health and
Disability Sector Standards, and fell well below an acceptable
standard. Accordingly, the rest home breached Right 4(2). The rest
home also failed to ensure that the woman received clinical care
that was of an appropriate standard, breaching Right 4(1). Adverse
comment was made with regard to the rest home's responsibility for
its staff's communication with the woman and her daughter, as her
primary contact person.
The facility manager failed to ensure that she and the other
staff provided adequate care and treatment, and breached Right
4(1). The facility manager also failed to ensure that she and the
other staff complied with policy and professional standards with
regard to documentation and breached Right 4(2). Adverse comment
was made about the facility manager, with regard to the failure of
staff to communicate adequately with the woman's daughter regarding
her transfer to hospital.
The clinical manager failed to ensure that the woman received
adequate clinical care with regard to her wounds in breach of Right
4(1). The clinical manager also failed to ensure that she and other
staff complied with policy and professional standards with regard
to documentation and breached Right 4(2). Adverse comment was made
about the clinical manager with regard to the failure of staff to
communicate with the woman regarding the infection in her leg.
Adverse comment was also made with regard to an RN's failure to
implement a wound care plan when the woman returned to the rest
home following her surgery.