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Decision 06HDC10115
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Names have been removed to protect privacy. Identifying
letters are assigned in alphabetical order and bear no relationship
to the person's actual name.
Health Care Assistant, Mrs C
A Rest Home
A Report by the Health and Disability Commissioner
Parties involved
Mr A Consumer
Mrs A Consumer's wife
Mrs B Consumer's daughter and power of
attorney
Mrs C Provider/Health care assistant
A rest home Provider/Private rest home
Ms D Health care assistant
Ms E Health care assistant
Ms F Human Resource Manager, the rest home
Ms G Site Manager, the rest home
Complaint
On 6 July 2006 the Commissioner received a complaint from the
Nursing Council of New Zealand about the services provided by
health care assistant Mrs C and a rest home, to resident Mr
A. The following issues were identified for
investigation:
- The adequacy and appropriateness of the care provided by
Mrs C to Mr A, in particular whether, on 17 May 2006
she:
- appropriately administered Mr A's medication as
prescribed
- appropriately documented the medication she gave to Mr
A
- appropriately reported any error in administering
medication to Mr A
- provided accurate information to Mrs A (Mr A's wife) about
the medication she administered to Mr A.
- The adequacy and appropriateness of the care provided by
the rest home to Mr A, in particular whether the rest
home:
- had appropriate systems in place for the administration of
medication to residents
- provided adequate information to Mr A's family and
attorney.
Mr A's wife, Mrs A, and daughter, Mrs B (who holds Enduring
Power of Attorney), were contacted, and they indicated that they
supported the complaint.
An investigation was commenced on 1 August 2006.
Information reviewed
Information gathered during investigation
Mrs C, a health care assistant, had worked in the dementia unit
at a rest home for ten years. The unit has 12 residents, including
Mr A. Mr A has Alzheimer's disease and is a challenging resident.
He is either continually active or asleep. He paces around and
around the rooms, and up and down the hall, and bangs on all the
doors, particularly the lounge doors. He pushes other residents out
of his way when he is pacing, and there is a risk that one of them
will fall.
Mrs C said that they had received many complaints about Mr A
from visitors and residents of the surrounding cottages
(independent living units) at the rest home. She had spoken to the
management, the geriatrician and other doctors about his medication
but she was told that there was nothing that could be done. She
thought that perhaps the rest home was not the right place for him
but there were no other suitable facilities in the area.
Medication
On 3 May 2006, Mr A was prescribed the following medication:
- quetiapine 25mg at midday (anti-psychotic medication), and
- lorazepam 0.5mg (half a tablet) at 5pm daily (for the treatment
of anxiety and insomnia), and quetiapine 25mg x 2 at 5pm.
This means that one tablet is given at midday, and two and one
half tablets are given at 5pm.
System of administration
The rest home manager, Ms G, explained that each resident has
medications dispensed in blister packs. All the 8am medication for
each patient for that month is dispensed on the one-month pack; the
midday medication is in a separate pack; and the 5pm medications
are in a third separate pack. Each pack has the resident's name and
identifying details in clear type pasted at the top (see Appendix
1). On the back of each blister (30 per month) is listed the names
of the drugs encased in the bubble (see Appendix 2).
All the blister packs for each time (8am, midday, 5pm) are
banded together with a rubber band. After all the 8am medications
have been administered, these packs are placed in the drug
cupboard, and the midday packs are taken out and placed on the
medication trolley in preparation for the next drug round. The
medication trolley is then locked.
Incident
On 17 May 2006, Mrs C worked a morning duty, from 7am to 3.30pm.
It was her responsibility to give the residents their medications
at 8am and at midday. At that time Mr A had been on the medication
regime for 14 days.
Mrs C said that she followed the same routine on 17 May as at
all the other times she gave the residents their medication. She
gave out the 8am medication and returned the packs to the drug
cupboard. She took the midday packs and placed them on the trolley.
It was close to midday when she began the next round, giving Mr A
his medication first. After he had taken the medication she
realised that she had given him his 5pm medication in error. She
had placed all the 5pm packs on the trolley by mistake. She did not
give any other medication. She returned the 5pm packs to the drug
cupboard and took the midday medications out of the cupboard and
continued the medication round. Mrs C did not report the error to
the registered nurse on duty, the clinical manager, or the doctor.
She did not complete an incident report or document the error in Mr
A's notes. When Mrs A visited her husband that afternoon, Mrs C did
not tell her about the error.
At 3pm on 17 May 2006, health care assistants Ms D and Ms E came
on duty. They received Mrs C's handover report. She told them that
she had mistakenly given Mr A his 5pm medications at midday and she
asked Ms D to give Mr A his midday medications at 5pm.
Ms D and Ms E said that Mrs C told them that she was trying an
experiment. She said that Mr A had been driving her mad all morning
and she wanted to see if receiving a double dose of his medication
at midday would keep him quiet in the afternoon. They said that Mrs
C said that she told Mrs A a "pack of lies". Mrs A had asked Mrs C
why her husband was asleep during visiting hours, but she could not
tell her the real reason. Ms D said that Mrs C used the expression
"out to the monk", meaning that Mr A was fast asleep.
Both Ms D and Ms E had the impression that Mrs C had
intentionally given Mr A his 5pm medication at midday. This was
particularly upsetting to Ms D because Mrs C expected her to
incorrectly administer the midday medications at 5pm, to comply
with Mrs C's "experiment".
Mrs C denied that this was how she described the error. She said
that this was not "an experiment as such". She meant that perhaps
it would suit Mr A to have a double dose at midday rather than 5pm
and, as she had made a mistake, they could see how he was affected.
Mrs C insisted that her actions were not deliberate. She knew she
had no authority to alter medication, and she knew the risks of
over-medication in the elderly. She had often spoken to management
about reducing medication if she thought residents were too sleepy
during the day.
Information to Mrs A
Mrs C said that she did not tell Mrs A "a pack of lies" but
simply did not say anything. She believes that relatives do not
want to hear anything unpleasant about their loved ones, and she
would prefer to give only positive reports when asked.
Ms D said that after Mrs C had gone home she contacted the
clinical nurse leader to report the matter. In the meantime, Mr A
was particularly sleepy and, when trying to make his way to the
toilet, fell at 3.45pm. The incident report read: "… Consequently
the resident has fallen due to the extra medication given but not
legally charted. A serious incident to be immediately addressed. No
clinical [order / staff] advised of this to be given."
Internal investigation
On 18 May, Mrs C was called to a meeting with Ms G and the
clinical nurse leader. In the minutes of the meeting Mrs C is said
to have stated:
"She told us that she would like this
medication to be trialled, this was because the resident is very
restless during the afternoon. [Ms G] informed her that this can
not be done before the doctor was consulted and gave consent for
this to happen. [Mrs C] admitted that she didn't complete an
error form and that was the only mistake she made."
Mrs C completed an incident form on 18 May 2006. At a second
meeting on 23 May, Mrs C said that after Mr A has his 5pm
medication he is "zonked out" and is given another dose at 8pm. In
her view it would be better to have the 5pm medication at midday
because he is so restless in the afternoon. She again insisted that
she had made a mistake and did not give the 5pm dose at midday
deliberately but, as she had, why not "trial it that way". She did
not tell Mrs A anything about the medication. Likewise, she would
not tell Mrs A about how stressful the other residents found Mr A,
because that is something relatives do not want to hear.
Mrs C told the investigating team that she knew of "things that
were happening but she never complains or comes down to see [the
clinical nurse leader]". She said that she "never reports on her
work mates". The records of the meeting state that Mrs C called Ms
D a "pimp" for informing Ms G about the error on 17 May. The
records also note that Ms G told Mrs C that all errors need to be
reported to the family, and "[Mrs C] referred to another error that
happened the night before … she asked [Ms G] how many incidents
happened and [Ms G] replied 'none since I've been at [the rest
home] because any such incidents will be handled in the same manner
by management'. [Mrs C] told us that we do not know what is going
on on the floor and [Ms G] told [Mrs C] that if errors are not
reported there is no way we will know." Mrs C was suspended on
full pay pending the rest home's investigation.
On 30 June 2006, the rest home notified the Nursing Council of
New Zealand that Mrs C:
"was dismissed on 30 May 2006 for a
serious breach of our drug administration policy in that she
deliberately increased a resident's medication (quetiapine and
lorazepam) 'as a trial', failed to advise the Nurse Leader or the
family of this, failed to complete the drug chart correctly to
record the change, failed to advise the other health care assistant
on duty at the time of the change in medication, failed to alert
her to the need for observation, failed to use the resident drug
administration chart correctly as our policy for this and other
residents."
Training in medication administration
Mrs C said that giving out medication was a big responsibility,
even with individual packaging. She said until 12 months ago it was
the responsibility of the registered or enrolled nurse to
administer medications. As trained staff left and had not been
replaced, this responsibility had fallen to experienced health care
providers. She said she had worked at the rest home for 15 years,
five years of which were in the hospital wing at the rest home. She
did not give medications there. She has had no formal nursing
training.
The rest home's records show that Mrs C was trained to give
medication. She successfully completed a medication administration
programme on 9 February 2000 and a health care assistant medication
administration assessment on 15 November 2004. The assessment
included a five point pre-administration check to ensure correct
drug administration: ensuring the right person, right drug, right
dose, right time and right route. Mrs C correctly answered what she
was to do if she made a drug administration error.
On 10 July 2004, the rest home tested Mrs C's knowledge on its
restraining policy. The test included a question on four ways to
restrain residents. Mrs C included approved medication to take the
"edge off a resident's behaviour". This answer was marked
incorrect.
Ms G advised that as far as she was aware, the rest home had
complied with all legislative and contractual requirements in
relation to teaching health care providers to give medications
correctly. All staff have to complete the medication management and
training programme as stated in the rest home manual. They have to
demonstrate competency before they are allowed to give medications.
All medication errors have to be reported, as stated in the manual,
be investigated by the clinical nurse leader, and have remedial
action taken as required and data collected to identify trends.
This is "benchmarked monthly" with other facilities of the
organisation.
Incident reporting policy
The rest home's Accident/Incident Report, Investigation and
Analysis policy states that an "incident" includes a medical error
and that the family must be notified of the error.
Code of Health and Disability Services Consumers' Rights
The following Rights in the Code of Health and Disability
Services Consumers' Rights are applicable to this complaint:
RIGHT 4
Right to Services of an
Appropriate Standard
(1) Every consumer has the right to have services
provided with reasonable care and skill.
RIGHT 6
Right to be Fully
Informed
(1) Every consumer has the right to the information
that a reasonable consumer, in that consumer's circumstances, would
expect to receive, …
Other Relevant Standards
The Ministry of Health's "Safe Management of Medicines, A Guide
for Managers of Old People's Homes" (1994) states:
"Message
Every manager of a residential care facility must take all
reasonable steps to ensure that at all times the storage,
administration and disposal of medicines are strictly controlled
and that safety, efficacy and accuracy are maintained with respect
to 'the right dose being administered to the right person in the
right form at the right time', as prescribed by the medical
practitioner.
Administration of Medicines
Under no circumstances give a medicine to anyone except the
person it was prescribed for.
Check prepared daily doses against the Resident Medication
Profile and enter them on the Medication Administration Record for
signing off as the dose is administered.
Use the original dispensed container or unit dose pack to
administer medicines.
If this is not possible management must arrange a suitable
alternative system which ensures that the right dose is
administered to the right person at the right time. Take all
reasonable steps to ensure strict control of storage and
administration of medicines - even during the Medication
Round."
Opinion
This report is the opinion of Rae Lamb, Deputy Commissioner, and
is made in accordance with the power delegated to her by the
Commissioner.
Opinion: Breach - Mrs C
Under Right 4(1) of the Code of Health and Disability Services
Consumers' Rights Mr A had the right to services provided with
reasonable care and skill. Mr A's daughter, Mrs B, who holds
enduring power of attorney, had the right to information about his
care that a reasonable consumer would expect to receive (Right
6(1)).
On 17 May 2006, Mrs C, a health care assistant at the rest home
gave the 8am medications to the residents of the dementia unit. She
placed the 8am packs back into the locked drug cupboard and placed
what she thought were the midday packs in the drug trolley in
preparation for the medication round at midday.
However, when Mrs C gave the medications to Mr A, the first
resident to receive his medication at midday, she gave him the 5pm
dose. She then noticed that these were the 5pm packs, realised her
error and returned the packs to the cupboard, retrieved the midday
packs and continued her drug round. Mrs C had given Mr A two
and a half tablets instead of half a tablet (twice the amount of
anti-psychotic medication and a dose of a sedative that he normally
had only in the evening). Clearly Mrs C did not complete the
five-point pre-administration check as she had been trained to do
to confirm the right patient, right dose, right drug, right time,
and right route. She made two mistakes: the wrong dose at the wrong
time.
Mrs C's next mistake was not reporting her error to Mr A's
doctor, the clinical nurse leader, her colleague on duty, Mrs A or
Mrs B, as required by the rest home's incident reporting
procedures. She did not report it to anyone. She signed the midday
medications as being correct, and did not record the matter in Mr
A's clinical notes or complete an incident form. She stated that as
Mr A had been particularly noisy and active that morning she would
try "an experiment" and see if increasing his midday medication
affected his behaviour.
Ms D and Ms E came on duty at 3pm and received a handover report
from Mrs C. She told them that she had made a mistake but wanted to
"experiment" to see if Mr A was quiet in the afternoon after having
the double dose of quetiapine, plus the lorazepam at midday instead
of 5pm. Ms D was scheduled to give the 5pm medication, and Mrs C
asked her to give the midday quetiapine 25mg at 5pm. After Mrs C
left for the day, Ms D reported the error. Ms D was very upset that
Mrs C would ask her to falsely document Mr A's records.
Ms D and Ms E had the impression that Mrs C gave Mr A the wrong
medication deliberately, but Mrs C denied this. Mrs C said that her
mistake had been genuine but she thought Mr A would be better with
the larger dose of quetiapine during the day. If that proved to be
the case, she thought they could ask the geriatrician or doctor to
alter his medications.
Mrs C's failure to report her mistake put Mr A at risk. Allowing
Mr A to be mobile under that level of sedation put him at increased
risk of injury. After Mrs C finished for the day, Ms E found Mr A
on the floor, having fallen while trying to get to the toilet.
Mrs C told the rest home investigating team that she knew of
lots of mistakes that are made by care assistants at the rest home,
but she does not report them. In my opinion, Mrs C's loyalty is
misguided. Her primary responsibility is to the residents in her
care and keeping them safe. Errors can only be prevented if each
incident is investigated to find the reason it occurred. It is not
a matter of telling on your mates, but creating a culture of
learning. Making mistakes is a part of human nature, and each
mistake, if examined openly and honestly, provides a forum for
learning about how improvements can be made, thus improving the
quality of care.
Ms D acted appropriately in reporting the error. Although Mrs C
said that her action in giving Mr A his medication at the wrong
time was not deliberate, I find it surprising that she would not
have noticed the different number of tablets in his usual lunchtime
dose. It was a serious error, and her subsequent actions show an
alarming lack of judgement. Mrs C seems to have no insight into her
responsibilities to Mr A or the other residents in the dementia
unit.
Mrs C knew the policy for reporting a medication error (as
evidenced by her correct answers on assessment) and told other
caregivers about the error, but did not report it. This conduct
suggests an attempt to cover up the error. Mrs C's failure to
report the incident meant that Mr A was not adequately monitored
and suffered a fall. She expected Ms D to give the wrong
medication at 5pm. Mrs C failed to provide Mr A with an appropriate
standard of care, and her actions on discovering her mistake were
dishonest. Accordingly, she breached Right 4(1) of the Code.
Mrs C did not take the necessary steps to ensure that the matter
was brought to the attention of Mrs B or Mrs A when she had every
opportunity to do so. Mrs A had visited her husband that afternoon
and asked why he was so sleepy. Mrs C could have told her of the
mix-up. The information I have gathered suggests that no
information about the medication error was passed on to Mr A, his
enduring power of attorney Mrs B (Under Right 6(1) of the
Code), or his wife (under the rest home's reporting policy). The
first Mr A's family heard of the error was when HDC called them to
see whether they supported the complaint. In my view, this is
unacceptable.
Had Mrs C properly reported the event, as she was expected to
do, Ms G could have reported the matter to Mrs B, who holds
enduring power of attorney for Mr A. Accordingly, Mrs C breached
Right 6(1) of the Code.
Opinion: No Beach - The Rest Home
Direct liability
Residential care facilities are required to provide services of
an appropriate standard, and this includes systems for the safe
administration of medication to residents. The rest home had its
residents' medications dispensed into blister packs by the
pharmacy. Each resident's name and the time for administration was
clearly marked at the top of the pack, and each tablet contained in
the bubble was named on the back of the pack.
The Health and Disability Sector Standards require residential
care facilities to have systems that comply with legislative and
regulatory requirements. This means that the rest home was required
to have systems, policies and procedures for the safe and
appropriate management of each step in the process of giving
residents their medicines - from prescribing and dispensing
medicines to documenting service providers' responsibilities at
each stage of the process. At the rest home, caregivers were
authorised to administer residents' medication only after they had
satisfactorily completed its training programme, and knew the
adverse effects of common medicines, and had demonstrated what to
do if an error occurred. I am therefore satisfied that the rest
home meets its legal and regulatory requirements in this
regard.
However, I have reviewed the incident reporting policy and note
that the checklist includes a brief requirement to explain the
incident to the family. This did not occur in Mr A's case.
Although the incident did not cause any significant injury to Mr A,
Mrs B was entitled to know that the rest home had adequately
assessed the need for any follow-up care and taken steps to ensure
that a similar error did not occur again.
My concern is that there may have been some complacency because
Mr A lacked the competence to understand any explanation about the
error, and Mrs B was not immediately available. A facility has a
responsibility to provide the same level of information to an
enduring power of attorney as they would a competent consumer. In
summary, therefore, the policy at the rest home is not adequate (as
it did not require an explanation for the consumer if competent),
and I will ask it to rectify the matter.
Vicarious liability
In addition to any direct liability for a breach of the Code,
employers may be vicariously liable under section 72(2) of the
Health and Disability Commissioner Act 1994 for any breach of the
Code by an employee. Under section 72(5), it is a defence for an
employing authority to prove that it took such steps as were
reasonably practicable to prevent the employee from doing, or
omitting to do, that which breached the Code.
Mrs C was employed at the rest home. On learning of the error,
Ms G met with Mrs C to inform her that an investigation was
underway. On 23 May Ms G suspended Mrs C because of concerns about
her safety to practise. She has subsequently been dismissed.
I have reviewed Mrs C's training records. The rest home had
provided Mrs C with training on the administration of medication,
and followed this with a written assessment. The rest home was able
to provide documentation of Mrs C's success in this assessment. I
am satisfied that Mrs C knew how to administer medications safely.
The error was not due to a systems failure but to Mrs C's failure
to follow the policy for pre-checking medication before it was
administered. Accordingly, in my opinion, the rest home is not
vicariously liable for Mrs C's breach of Right 4(1) of the
Code.
Adverse comment
When Mr A was admitted to the rest home, Mrs B held an enduring
power of attorney for her father's care and welfare, which entitled
her to receive information and make decisions on his behalf.
Clause 4 of the Code provides that for the purposes of Right
6, "consumer" includes a person entitled to give consent on behalf
of that consumer. An effective system of communication between Mr
A's wife, his daughter and nursing staff was required because of Mr
A's complex care needs. The fact that Mrs A visits her husband
regularly and Mrs B lives in another part of the country and does
not see her father very often does not preclude this obligation.
These factors needed to be included in the communication plan.
It would appear that Ms G did not inform Mrs B or Mrs A of the
error in Mr A's medication. Mrs C did not confirm her error
until the following day, when she was called to a meeting with Ms G
and the clinical nurse leader. By that time, the effects of the
medication were known, and Mrs A had been in to visit her husband.
Ms G should have ensured that the family was told of the error.
Mrs B was entitled to receive this information, as she has
the legal authority to make decisions and give consent on
Mr A's behalf. To do this, she must have all relevant
information in her possession. Accordingly, I will bring this
matter to the rest home's attention and ask that they ensure that
appropriate people are promptly informed about errors.
Recommendations
Mrs C
I recommended that Mrs C take the following action:
- Apologise to Mrs B and Mrs A for her breach of the Code of
Health and Disability Services Consumers' Rights.
Mrs C has apologised, and her letter has been sent to Mrs B and
Mrs A. She has also confirmed that her new employers have been
informed of this investigation and my findings.
The Rest Home
I recommended that the rest home take the following actions:
- Use my report to educate staff on the importance of openly
reporting errors in a timely fashion.
- Review its practice in regard to promptly disclosing errors to
residents or their representatives, and report back to me on the
changes it has made.
The rest home has advised me that it is alerting staff about the
importance of advising those holding an enduring power of attorney,
about any care issues or changes in a resident's condition.
Follow-up actions
- Mrs C will be referred to the Director of Proceedings in
accordance with section 45(2)(f) of the Health and Disability
Commissioner Act 1994 for the purpose of deciding whether any
proceedings should be taken.
- A copy of this report, with details identifying the parties
removed, will be sent to HealthCare Providers New Zealand, and the
DHBNZ Quality and Safe Use of Medicines Group, and placed on the
Health and Disability Commissioner website, www.hdc.org.nz, for educational
purposes.
Addendum
The Director of Proceedings filed a claim in the Human Rights
Review Tribunal alleging breaches of Right 4 of the Code. The
Tribunal found that the health care assistant did not deliberately
alter the resident's medication, but that having made a mistake,
she then decided to experiment and she failed to report the
medication error. The Tribunal therefore declared that there was a
breach of Right 4(2) in failing to comply with relevant standards,
and 4(5) in failing to co-operate with other providers to ensure
quality and continuity of services.
Appendix 1
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Appendix 2
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