Appendix A: Timeline of recorded weights for Mrs A

Appendix B: In-house clinical advice to Commissioner

The following advice was obtained from RN Jane Ferreira:

‘1.    Thank you for the request that I provide clinical advice in relation to the complaint about the care provided by Oceania Healthcare. In preparing the advice on this case to the best of my knowledge I have no personal or professional conflict of interest. I agree to follow the Commissioner’s Guidelines for Independent Advisors.

2.     Documents reviewed.

Consumer complaint received 24 December 2020

Provider responses dated 3 May 2021 and 2 May 2023

Clinical file information including nursing assessments, care plans, monitoring forms, progress notes, GP records, medication prescription, health directives, and significant event investigation information.

Organisational policies including falls management, COVID-19 management, and related protocols.

Additional information received 3 May 2023 including clinical records, incident records and investigation reports, nursing assessments, care plans, observation records, equipment checks, medication prescription and administration records, communication records, meeting minutes, shift rosters, education, and training records, revised organisational policies with evidence of improvement initiatives.

3.     Complaint

[Mrs A’s] daughter [Mrs B] has raised concern regarding the care provided to her mother between 28 [Month1] and 9 [Month5] while resident at Otumarama Care Home and Whareama Care Home. Her concerns relate to delayed treatment, falls management, nutritional needs, clinical care, and communication.

4.     Review of clinical records

For each question, I am asked to advise on what is the standard of care and/or accepted practice? If there has been a departure from the standard of care or accepted practice, how significant a departure do you consider this to be? How would it be viewed by your peers? Recommendations for improvement that may help to prevent a similar occurrence in future. In particular, comment on:

·     Falls management, weight management and nutritional needs, medication management, communication, education and training.

·     Any additional areas for comment.

Background

[Mrs A] was admitted to Otumarama Care Home on 28 [Month1] at hospital level of care. Her medical history included extra-axial meningioma, hypopituitarism, gastro-oesophageal reflux disease (GORD), macular degeneration, osteoporosis, dorsolumbar scoliosis, recurrent falls, urinary tract infections, lower limb cellulitis, hearing loss, weight loss, anxiety, and frailty. Prior to her admission [Mrs A] had experienced a recent respiratory tract infection and was diagnosed with a related hypoactive delirium, minor adrenal crisis, and acute kidney injury. File information shows that [Mrs A] required regular assistance from carers to meet activities of daily living. She had a very supportive family who were actively involved in her care. [Mrs A] experienced a fall event on 6 [Month3], and was transferred to hospital on 8 [Month3] with a suspected head injury. On 15 [Month3] she was discharged to Whareama Care Home for ongoing care and passed away on 9 [Month5]. I extend my condolences to [Mrs A’s] family at this time.

A)     Was [Mrs A’s] falls risk adequately assessed with appropriate measures put in place to manage and/or mitigate her risk of falls.

Preadmission health information indicates that [Mrs A] had been assessed as a high falls risk due to her health history, noting variable levels of mobility and function. The interRAI assessment 16 [Month1] discussed associated falls risk factors which included posture and vision, a hypoactive delirium with altered mental state, and an unfamiliar in-patient care environment, noting that [Mrs A] required assistance at all times for safety.

[Mrs A] was admitted to Otumarama care home on 28 [Month1] and her falls risk was assessed by a registered nurse (RN) in line with the organisation’s Falls Management policy. The Falls Risk Assessment Tool (FRAT) provided an initial risk score of 9/20, with recognition of additional risk factors resulting in a High falls risk status. An interim care plan was commenced which included a range of generic falls minimisation measures, which would be considered appropriate in the circumstances.

The Person-Centred Care Plan (PCCP) policy and Falls Management policy state that an interRAI clinical assessment will be completed within 21 days of admission, with data used to inform a long-term nursing care plan. File evidence shows that [Mrs A’s] interRAI assessment was completed on 14 [Month2], which is within recommended timeframes. The Falls management care plan (section 10) reflects that falls minimisation strategies were in place, with evidence of input from [Mrs A’s] daughter and EPOA, who was her primary carer while living in the community. These include the use of a sensor mat, suitable lighting, the application of walking frame and bed brakes, and ensuring items of importance, including a call bell, were within reach.

The clinical record shows that [Mrs A] was regularly seen by a general practitioner (GP) or nurse practitioner (NP) during her admission. GP notes from the virtual admission assessment 29 [Month1] report a high falls risk status noting strategies were in place. File information reflects evidence of regular physiotherapist assessment and involvement in [Mrs A’s] care. Physiotherapy notes 4 [Month2] acknowledge COVID-19 isolation requirements for new care home admissions, in line with pandemic measures at the time, with a proposed assessment timeline. [Mrs A] was seen by the physiotherapist on 18 [Month2] and assessed as a high falls risk. Physiotherapy notes describe observed risk-taking, noting [Mrs A] was standing unsupervised in her room to adjust curtains, and that the bell mat had not activated. [Mrs A’s] care plan refers to completion of regular wellbeing checks by carers, in line with interventions in the Falls Management policy (5.2). The policy (5.5) provides guidance regarding the care and management of sensor mats, including mat safety checks per shift, actions, and reporting responsibilities for identified faults. It is unclear if these interventions were reviewed by the RN team following the identified risk and what additional safety measures were put in place to ensure call bell functions and safety needs were maintained.

[Mrs A] experienced a fall event in her bedroom on 6 [Month3]. File information shows [Mrs A] was assessed post-fall by an RN in line with the organisation’s policy for the post-fall management of witnessed and unwitnessed fall events. There is evidence that neurological observations were commenced, and that communication and reporting requirements were completed, in line with recommended incident management responsibilities. As outlined in the manager’s incident follow up, [Mrs A’s] falls risk was reviewed by an RN on 6 [Month3] with suitable post-fall interventions in place and seen by a physiotherapist on 8 [Month3], prior to hospital transfer for assessment of identified decline.

The care record reflects that [Mrs A] was admitted to Whareama Care Home from hospital on 15 [Month3]. The provider has advised that [Mrs A’s] continuous electronic care record was transferred from Otumarama care home to Whareama care home at the time. The PCCP policy (6.4.1) states that the care team are guided by the instructions in the care plan which is the basis for all care delivery. It is unclear what was communicated to the care team on admission regarding [Mrs A’s] medical history, level of frailty, associated nursing care needs, and safety requirements.  

Progress notes discuss [Mrs A’s] arrival in the care home, outline her dietary needs and state she was a high falls risk however it is unclear from the submitted evidence whether nursing assessments were completed, or care planning reviewed and updated, in line with organisational policies. It appears that baseline observations, specific dietary requirements and allergies were recorded however there is no evidence that a FRAT was completed, pain, mobility or skin integrity assessed, or a safety risk management plan considered given the recent fall event resulting in hospitalisation. An interRAI assessment was completed on 20 [Month4] and refers to the fall event 6 [Month3] which resulted in hospital admission, but there is no discussion of reassessed falls risk or reviewed safety needs, which would be considered accepted practice given [Mrs A’s] identified frailty and associated health conditions. As outlined in the provider response, there does not appear to be a review of falls management and risk prevention strategies in care planning which would be accepted practice in the circumstances. In addition, there is no discussion of specific care and safety strategies offered to support [Mrs A], considering another change in her environment, diagnosed hypoactive delirium, recent fall, and frailty. Given the identified risk factors, accepted practice would be to develop a personalised, short-term care plan to support care and safety needs during the settling-in phase to the new care home. This is outlined in the organisation’s admission processes, and Clinical Manager’s Orientation Manual.

[Mrs A] was seen by a physiotherapist on 16 [Month3], with assessment comments referring to a markedly flexed C-spine, noting difficulties with posture and positioning. There is limited discussion in care planning regarding changes to her mobility plan, including associated nursing responsibilities to skin integrity and pressure injury risk assessments, pain management and related health needs. Progress notes indicate that [Mrs A’s] level of mobility was improving, and physiotherapy notes 25 [Month3] discuss a trial of stand practice using a walking frame, but there is no evidence that a short-term care plan was commenced at this time to outline specific interventions and safety considerations.

From the evidence reviewed to respond to this question it appears that falls assessment and care planning processes met the required standards at Otumarama Care Home however there are identified weaknesses in nursing processes at Whareama Care Home. There appear to be opportunities for improvement in clinical processes and documentation standards regarding the completion of holistic and timely nursing assessments, care planning, and evaluation, which would be viewed similarly by my peers.

·     Departure from accepted practice: Moderate to significant.

b) Do the clinical notes indicate how often [Mrs A’s] falls risk was assessed? When [Mrs A] fell in her room on 6 [Month3] at Otumarama Care Home, was the RN post-fall assessment adequate?

The PCCP policy states that nursing assessments (including falls risk) will be completed on admission, six monthly as part of the resident review process, and repeated as indicated, which is in line with accepted practice standards (HQSC, 2019). As outlined in question (A), file evidence shows [Mrs A’s] falls risk was assessed by an RN on admission to Otumarama Care Home as part of the admitting nurse’s responsibilities and reviewed again following her fall event on 6 [Month3]. GP notes from the virtual medical admission assessment 29 [Month1] record that [Mrs A] was a high falls risk, noting prevention strategies were in place. [Mrs A’s] falls risk was also assessed by a physiotherapist at both care homes, with physiotherapy notes reporting that [Mrs A] was at high risk of falls.

The falls management policy provides guidance regarding post-fall responsibilities, which includes the review of a resident’s falls risk. [Mrs A’s] falls risk was reassessed by an RN on 6 [Month3] with a risk score of 13/20 (medium risk), noting that she had no previous fall history recorded. While checklist risk factors were selected, automatic high-risk factors were not selected on the tool, which presents a coaching opportunity regarding holistic nursing assessment. Post-fall neurological observations were completed across 6, 7 and 8 [Month3] in line with organisational policies in place at the time. Short-term care plans were commenced for the identified bruising which would be considered appropriate nursing practice in the circumstances.

A nutritional monitoring form was in place at the time due to weight-loss concerns, with evidence provided of limited oral intake during the timeframe in question. There does not appear to be evidence that pain assessments were completed at this time, however progress notes discuss the administration of prescribed as-required (PRN) pain relief (Paracetamol). File information shows care concerns were escalated by the nursing team to the GP with a post-fall review scheduled for 8 [Month3], and that a physiotherapist assessment occurred on 8 [Month3], which would be considered accepted practice.

From the evidence reviewed to respond to this question it appears that the post-fall assessment and related actions completed by the RN team on 6 [Month3] were appropriate in the circumstances.

·     Departure from accepted practice: Nil

c) Was the delay in seeking treatment from the hospital appropriate? Please review the organisation’s “falls” policies, “clinical incident/accidents sentinel events” policy, and “clinical escalation pathway” document and advise if staff actions aligned with policies at the time of the event.

The Falls Management policy in place at the time of the event provides discussion of falls risk assessment steps and care planning processes, with clear guidance about how to manage fall events and post-event responsibilities. The policy references the Health Quality and Safety Commission’s (HQSC) Frailty Care Guidelines Falls Prevention resource which outlines steps for witnessed and unwitnessed falls (HQSC, 2019). The organisation’s Falls Risk Assessment Tool (FRAT), located within the electronic care record, appears to provide relevant prompts to guide event assessment, escalation, and reporting. The Falls Management policy provides reference to the Clinical Escalation Pathway, noting if changes are causing concern, to phone the GP/NP or 111 for an ambulance. The policy discusses post-event processes such as completion of falls analysis, corrective actions, benchmarking, and quality improvement interventions, in line with incident management and clinical governance requirements.

The Clinical Incident/Accidents Sentinel Events policy (2020) appears to provide guidance in line with relevant sector legislation and contractual requirements. The policy outlines organisational expectations for incident management standards, role responsibilities, reporting, education, and training requirements. The policy includes decision steps for event escalation and investigation with reference to timeframes, corrective actions, and event feedback.

As outlined in the provider response, the Clinical Escalation Pathway (2022) is a new process implemented in response to this complaint. The document references the revised Nga Paerewa Health and Disability Sector Standards, and the HQSC Frailty Care Guides, which are recognised clinical resources (HQSC, 2019).

From the information reviewed it appears the policy guidance in place at the time was appropriate to guide clinical decision-making in the circumstances. There is evidence that steps were commenced by the RN team to monitor [Mrs A’s] post-fall status, however it is unclear if her underlying health status was considered as a contributing factor to the fall event, and subsequent decline.

The Falls Management policy states that if the post-fall assessment or neurological observations do not raise any concerns, that GP/NP notification may not be required immediately. Progress notes 7 [Month3] indicate that [Mrs A] was monitored overnight post-fall and appeared comfortable. However, an entry from the morning shift on 7 [Month3] states “looks weak, restless, nauseated and holding the front of her head. RN assessed”. The entry states that [Mrs A] was assisted with meals and ate a small amount, as evidenced on the nutritional record form. RN entries on 7 [Month3] refer to a bruise located on [Mrs A’s] head, left frontal aspect, but report that [Mrs A] was alert, orientated and that neurological observations were within normal range. The entry states that [Mrs A] was restless after 11am, complained of pain and was given prescribed paracetamol tablets, however there is no discussion of a pain score, or evidence that a pain assessment was completed at this time. RN progress notes reflect that [Mrs A’s] daughter expressed concern regarding falls-related injury and requested hospital transfer for an X-ray. The entry refers to RN escalation to the CM for senior nurse guidance which would be considered accepted nursing practice. Nursing entries reflect that a GP visit was scheduled for 8 [Month3], with a plan to continue observations and if signs of head injury or concern to send to hospital, which is in line with policy guidance.

A PM shift entry on 7 [Month3] states “very less food, fluid intake”. The PM shift RN entry reports “no complaints of nausea or vomit(ing), alert, talking normally, walking well in bedroom ...” An RN entry from the nightshift reported that [Mrs A] presented with restlessness, showed discomfort, no reports of pain but that she was “unable to define her exact problem”. There is no evidence that a pain assessment or wider nursing assessment was completed at this time. The entry states that a prescribed PRN antipsychotic medication (Quetiapine) was administered, however the rationale for this action is unclear. Prescribed pain relief (Paracetamol) may have been an appropriate intervention when considering associated risk factors, however medication administration records were not provided in the evidence bundle to inform further comment. It is unclear if [Mrs A’s] vital signs, hydration status or elimination patterns were reviewed which would be considered accepted practice in the circumstances.

File information reflects that the incident report was reviewed by the business and care manager and an event summary completed, in line with incident management responsibilities. The event statement reports that the team were alerted (by a call bell) and found [Mrs A] standing on her sensor mat, saw her lose balance, fall, and hit her head. Post-fall steps are reflected, noting family and the GP were informed. Physiotherapy notes 8 [Month3] state that [Mrs A] presented with reported and observed pain, was unable to attain or maintain a sitting position, and was unsafe to attempt stand transfers. The incident report was updated the same day stating that [Mrs A] was drowsy, unable to sit unaided, and sent to hospital for assessment with query dehydration or injury-related concerns.

Progress note entries reviewed prior to the fall event indicate that the care team were concerned about [Mrs A’s] health and wellbeing, discussing frailty, mood, reduced oral intake, irregular bowel patterns and safety concerns. An entry on 2 [Month3] refers to finding [Mrs A] kneeling on the floor and on 4 [Month3] that sensor mats were positioned on both sides of the bed, however it does not appear that monitoring frequency was increased at this time. Contributing factors selected on the event report include medical diagnoses, call bell not used, did not wait/ask for assistance. It is unclear whether the care record was reviewed by the leadership team for additional signs of concern, such as constipation, dehydration, or infection, to inform post-fall actions. There is no evidence of wider analysis of contributing factors or that a corrective action plan was considered, particularly relating to pain management and recognition of resident decline, which would be considered accepted practice.

From the evidence reviewed to respond to this question it appears that while relevant policies were available to guide team actions, it appears the RN team did not recognise signs of gradual resident decline as a contributing factor to [Mrs A’s] fall event or consider underlying health and wellbeing factors in post-fall management. There appear to be concerns with post-event clinical leadership, nursing assessment and pain management which would be viewed similarly by my peers.

The STOP AND WATCH tool partnered with the clinical reasoning guide would be considered a recommended resource to support RN assessment steps and related decision-making (HQSC, 2019). I note this has since been integrated into the organisation’s new Clinical Escalation Pathway (2022).

·     Departure from accepted practice: Moderate to significant.

d) Please review the notes, and comment if the communication between care home staff (in both care homes) and [Mrs B] (complainant) was appropriate and adequate, and why/why not?

File information reflects that [Mrs A’s] daughter, [Mrs B], was her primary carer, advocate, and support person prior to admission to long-term care. As outlined in clinical assessment comments, [Mrs A] was well known to community health teams and her goal in [Month1] was to return to her home for ongoing care. Assessment comments discuss the challenges experienced during [Mrs A’s] acute-care admission which impacted her wellbeing, referring to the COVID-19 pandemic and associated care and isolation measures, separation from family and health decline, followed by transitioning to a long-term residential care setting.

The Age-Related Residential Care (ARRC) Agreement and Health and Disability Service (HDSS) Standards require service providers to acknowledge and involve the consumer and their nominated representatives in all aspects of care. The submitted organisational policies and procedures reflect the provider’s responsibilities to ensure family/whānau were involved in resident care. The PCCP policy and Multidisciplinary Review Policy (2020) refer to admission responsibilities and resident review process, acknowledging collaboration between the care team, resident, their nominated representative, and family/whānau. File information indicates that usual care home admission interactions were disrupted due to COVID-19 pandemic measures in place at the time, and that restricted visiting impacted the care and relationship process.

The family/whānau communication record and progress note entries reflect that [Mrs B] regularly visited her mother and provided feedback to the care team regarding her mother’s needs. [Mrs A’s] care plan reflects EPOA review and input in [Month2], with the inclusion of additional personalised strategies to assist the team to meet [Mrs A’s] needs in a meaningful way. There is evidence that case conferences were held on 22 [Month3] and 3 [Month4] following [Mrs A’s] admission to Whareama Care Home however there is no evidence of further care plan review which would be considered accepted practice in the circumstances.

Email communications and the care record provide evidence of interaction between both care home teams and [Mrs B], as [Mrs A’s] nominated representative. Entries in the care record indicate the nursing team escalated concerns to the care home leaders, however, it is unclear if meetings were held between [Mrs B] and care home managers to discuss concerns and find resolution, in line with accepted communication and complaint management processes. There is discussion within the care record that case conferences occurred, however there is no evidence provided of meeting minutes shared with [Mrs B] in response to her concerns to outline agreed approaches to care decisions, plans or reviews, in line with the PCCP policy (7.2; 9).

As discussed in question (J), [Mrs B] expressed concern regarding the safe administration of prescribed medications on 9 [Month5]. Given her knowledge and experience as [Mrs A’s] previous primary carer, it is unclear why the RN team did not respond to her request as EPOA, to seek medical advice or transfer [Mrs A] to hospital for further assessment, in line with appropriate service standards. [Mrs B] has discussed her experiences about interactions with care home team. The provider response has acknowledged [Mrs B’s] concerns regarding professional standards of communication and conduct and discussed improvements made to organisational policy and processes. It appears the organisation’s communication policy and complaint’s management policy were not provided in the evidence bundle which would inform further comment.

From the evidence reviewed to respond to this question it appears the level of communication met the minimum standard in the circumstances. There appear to be opportunities for improvement with consumer engagement, care partnership and documentation standards in line with PCCP policy requirements, which may be viewed similarly by my peers.

·     Departure from accepted practice: Mild to moderate

e) Was [Mrs A’s] weight properly measured on admission to the different care homes, and regularly after, and is there a clear record of her weights? Do the clinical notes indicate which weigh scale was used each time her weight was measured, and is this documented in the notes in accordance with their “setting weight goals and interventions” document (such as time weighed, scale used etc)? If weight loss was recorded, did the staff take action, and if so, what?

File evidence shows that [Mrs A] was at risk of undernutrition as outlined in pre-admission assessments, and medical admission notes refers to weight loss. File evidence shows that [Mrs A] weighed 46.7kg on admission to Otumarama Care home. A short-term care plan to address weight loss was in place, 9 [Month2], with a goal to maintain a healthy weight range, in line with the organisation’s “Setting weight goals and interventions” guidelines (Feb 2019). The weight monitoring chart reports that she was weighed six times during [Month2], noting her weight had declined to 43kg on 30 [Month2]. She was weighed again on 6 [Month3] with a further decline to 41.2kg reported. There is evidence of evaluation provided, noting that a nutritional supplement was charted with weekly weighs in place per dietician instructions.

The long-term care plan refers to a goal to maintain a stable weight, noting that [Mrs A] will be provided with enough food and fluid of her choice, and be monitored for further weight loss. The care plan includes a list of likes and dislikes noting meal size as small due to a poor appetite, and that [Mrs A] was prescribed a nutritional supplement (Fortisip) twice daily. It notes that dietician input was not indicated at that time. There is no reference to the frequency of weighing, use of weight records and daily intake monitoring forms, or discussion of an evaluation plan. There is no discussion in care planning regarding the preferred use of weighing devices, however physiotherapy notes 25 [Month3] state that [Mrs A] was able to sit on a weigh scale (chair) which may indicate the approach used at the time. It does not appear that nursing information was reviewed or updated in response to the physiotherapist’s mobility assessment at the time which would be accepted practice.

[Mrs A] was admitted to Whareama Care Home on 15 [Month3] however there is no evidence that an admission weight was recorded as part of nursing responsibilities. The weight tracker indicates that [Mrs A’s] weight was first recorded on 25 [Month3] at 43kg, and again on 7 [Month5] at 43.4kg. There is no evidence provided that [Mrs A] was weighed during [Month4], which would be considered below acceptable standards when providing care for a vulnerable resident.

While progress note entries discuss nutritional intake, there is minimal discussion of weight management interventions or evidence of weight review by the RN team. The short-term and long-term care plans within the electronic care record commenced by Otumarama Care Home do not appear to have been reviewed post-hospitalisation by the admitting team at Whareama Care Home. There is no evidence that a short-term care plan was commenced by the admitting team in response to identified weight management concerns which would be considered accepted practice, as outlined in organisational policies.

[Mrs A] had been assessed as requiring hospital level care. Her care plan (1,10), 19 [Month2], reviewed 6 [Month3], outlined her mobility and transfer needs, noting [Mrs A] mobilised with a low walking frame and carer assistance. There is no discussion within the short-term or long-term care plans or physiotherapy notes about assessed preference for chair scale or hoist scale use as part of weight management.

The provider has submitted evidence of annual medical equipment checks completed by a service provider which includes performance tests of hoists, chargers, and batteries. File information shows that equipment at Otumarama Care Home, listed as a chair scale, hoist scale, and analogue floor scale, was performance verified on 12/7/19, 28/7/20, 12/7/21. Equipment at Whareama Care Home, listed as a chair scale, hoist scale, digital scale was performance verified 16/7/19, 29/7/20, 12/7/21.

From the evidence reviewed to respond to this question it appears that the management of [Mrs A’s] weight was not in line with recognised admission and ongoing care responsibilities while resident at Whareama Care Home. There appear to be opportunities for improvement in the clinical oversight of resident weight management, nursing assessment, care planning and evaluation, and documentation standards which would be viewed similarly by my peers.

·     Departure from accepted practice: Moderate to significant

f) Whether [Mrs A’s] diet and nutritional needs were properly assessed with an appropriate meal plan in place and was this in accordance with their “nutrition and hydration” policy? Were her food allergies properly documented and communicated to the staff?

Care home information indicates that [Mrs A’s] nutritional needs were assessed on admission to Otumarama Care Home in line with organisational polices and processes. Her allergy status was reflected in E’Case information, relevant care plan sections, and on her medication prescription information in Medimap. Preadmission information in the home care interRAI assessment flags dehydration risk, with assessment comments reporting that [Mrs A] needed encouragement with all fluids and intake, required modified equipment, a nutritional supplement and was under the care of a hospital dietician. Nursing admission information reports that [Mrs A] was described by family as known to eat very small meals and received a high energy, high protein (HEHP) diet.

[Mrs A’s] interRAI information reflects a risk of undernutrition with a BMI score of 19. The Nutrition and Hydration policy outlines care responsibilities with weight management, and guidance regarding unplanned weight loss with recognised interventions, in line with the HQSC Frailty Care Guide resources (HQSC, 2019). The care plan indicates that [Mrs A] was offered a HEHP diet with a nutritional supplement and file information reflects that her daughter was supportive with meal alternatives. The care plan (12) refers to food allergies and information-sharing with the kitchen team. The nutritional requirements form reflects allergies, noting a preferred small meal size with a weight-gain goal. Likes and dislikes were listed.

File information reflects that [Mrs A] was admitted to Whareama Care Home on 15 [Month3]. There is no evidence provided of nursing assessments completed on admission nor commencement of a short-term care plan to guide care and safety needs post-hospitalisation, during the settling-in phase to the new care home.

The interRAI assessment was reviewed 20 [Month4], which is outside of PCCP policy timeframes, and the long-term care plan was not updated in response to interRAI assessment findings, which raises concern regarding care planning practice and service delivery responsibilities. The interRAI assessment 20 [Month4] states that [Mrs A] was at high risk of undernutrition. There is no evidence that a new short-term care plan was commenced to manage her risk of weight loss. There is no evidence that further nursing assessment occurred, the GP was informed, or a dietician consulted. Given the identified nutritional risk it is unclear why the frequency of weight recording was not increased and associated monitoring forms commenced per policy guidelines.

The care plan (11, 12) states that [Mrs A] was allergic to onion and garlic causing vomiting and angioedema, and that kitchen teams had been informed of health and safety risks. Statements provided by kitchen personnel discuss the process of collecting resident nutritional information and communication of relevant data, such as published on a white board, which appears to be in line with policy guidelines.

File information reports an incident occurred on 23 [Month2] where [Mrs A] received the wrong meal. The manager’s comment on the incident event reported that [Mrs A] had been monitored by an RN, remained well and that risk mitigation steps had been put in place. The care record 3 [Month3] reflects incident follow-up by the clinical manager. The entry states that a new process had been implemented by the kitchen manager to ensure correct meal service, however the care plan was not updated to reflect what this safety measure was. The PCCP policy (6.4.1) Handover: states that “any changes to the resident care are the basis for all handovers. All care staff are guided by the instructions in the care plan which is the basis for all care delivery” with reference to points (D10.1, D10.2, 16.3) of the ARRC agreement. It is unclear if a safety alert was communicated to the care home teams, if kitchen and nursing information was updated or if improvements were shared with [Mrs A’s] EPOA, in line with policy and incident management processes.

From the evidence reviewed to respond to this question it appears the care provided to [Mrs A] was below the accepted standard in the circumstances. There appear to be departures in clinical oversight, nursing assessment, care planning, communication and documentation standards for at-risk residents which would be viewed similarly by my peers.

·     Departure from accepted practice: Significant

g) Please review notes and comment what assistance [Mrs A] required in terms of giving herself meals. Was this properly recorded and adhered to by staff? Please review notes dated 9 [Month5] (day [Mrs A] passed away), and comment on the appropriateness of her being left alone in her room for breakfast.

The nursing care plan (12), 19 [Month2], states that [Mrs A] had an assessed malnutrition risk of 4, indicating High Risk. Care plan information refers to a six-month history of dysphagia (swallowing difficulty) noting that [Mrs A] ate very slowly with personalised equipment, that meals were a purée texture and that she required full assistance and prompting with food and fluid intake. The care plan (12) lists physical difficulties with eating and drinking including unsteady hands, poor coordination, and low vision but does not specifically mention [Mrs A’s] stooped posture or provide guidance regarding safe, individualised positioning as identified in the physiotherapy assessment. The care plan (12) states that [Mrs A] will be positioned in bed or chair in readiness to eat, with food placed within reach, utensils placed in her hand with a prompt to start eating. The care plan states that during eating [Mrs A] “requires supervision and prompting throughout eating of meal”, noting she may require physical assistance at times.

Assessment comments in the medical admission state “chin on chest, pocketing food”, and to refer to Speech and Language Therapy (SLT) for advice on positioning, eating, and drinking. A specific care plan (2), 19 [Month2], was in place which provided further information about dietary requirements and safe swallow care. The assessment refers to a need for meal and drink assistance, noting some food spillage, pocketing of food in the mouth and long chew times. The care plan strategies state that during meals [Mrs A] required “supervision, prompting, and at times physical assistance”, which is also reflected in care plan (12). Care plan (2) refers to assessed swallowing difficulties with generic risk strategies discussed such as upright positioning, offering a purée diet, thin fluids, and time, however there is no discussion of specific safety measures introduced to reduce [Mrs A’s] risk of choking or aspiration, such as individualised positioning given her marked kyphosis, specific guidance regarding isolation and choke risk, call bell access or first-aid measures. Care plan strategies state to “go back and check on her, provide assistance as needed”, however there is no evidence that interventions were reviewed between 19 [Month2] and 9 [Month5].

File information shows that [Mrs A] had been assessed as requiring close supervision and assistance with all meals, and progress notes and communication records indicate that [Mrs A] usually had all her meals in the residents’ shared dining room where she could socialise and be safely supported. [Mrs B] has advised that during her visit on 8 [Month5] she informed the on-duty team that a family visit was planned for 10am 9 [Month5], and asked that [Mrs A] remain in the dining room after breakfast. Progress notes reviewed for the time in question do not reflect evidence of this communication request. It is unclear how information was handed over to the next shift in line with the PCCP policy, if a communication book or handover form was in use at the time or a verbal discussion was held between the teams on the day.

[Mrs B] has stated that she found her mother in her bedroom on the day in question and not in the dining room as requested. She has expressed concern at finding [Mrs A] positioned facing away from the doorway, with no call bell available and her breakfast tray still present. It is unclear what shift planning occurred given the change in [Mrs A’s] breakfast location, and what care and safety measures were discussed between the RN and care team as part of shift management responsibilities to ensure safe and appropriate service delivery. Recommended RN practise would be to ensure that a high-risk resident was supervised and well supported, as had been clearly outlined in [Mrs A’s] care plan 19 [Month2], and that all unmet needs had been safely addressed prior to the planned family visit.

[Mrs A’s] Advance Care Directive form, 22 [Month3], outlined her goals for care, which stated to have dignity, and included personalised information with prompts regarding her care needs such as ‘I am not good at ringing my bell, be sure to check on me’. Orientation manuals and role resources refer to the PCCP policy and the Health and Disability Commissioner’s Code of Rights, noting that care provided will be consistent with what is written in the person-centred care plan. The provider has acknowledged the lack of care planning in place at the time and apologised, with discussion of improvements made in response to learnings from this complaint.

From the evidence reviewed to respond to this question there appear to be significant concerns with clinical leadership, communication, documentation standards, and delivery of safe and appropriate care to [Mrs A] during the timeframe in question, which would be viewed similarly by my peers.

·     Departure from accepted practice: Significant

h) Please review the incident forms from Whareama and comment if there was a choking incident that happened in the dining room recorded, which staff were involved, and any details about this incident.

The submitted incident record lists three reported events during [Mrs A’s] admission which occurred in [Month2] and [Month3] while resident at Otumarama Care Home. There is no evidence of any reported incidents or associated discussion of a choking event within care record entries between 15 [Month3] and 9 [Month5] while [Mrs A] was resident at Whareama Care Home.

As a comment, care plan (2) provides strategies to reduce the risk of choking events, however there is no guidance provided regarding potential event management such as the application of first aid measures, incident reporting processes, and related nursing responsibilities to care and safety needs in line with organisational policies which presents an improvement opportunity.

i)     Please review the “person centred care planning” policy, was this adhered to by the staff?

The Person-Centred Care Planning (PCCP) policy provides organisational guidance regarding resident assessment and care planning responsibilities with reference to sector legislation. The policy lists sources for data collection with timeframes for nursing assessment, goal setting, personalised care plan development, and evaluation in line with contractual requirements. The PCCP states that where progress is different than that expected, changes are made to supports in the care plan, in partnership with the resident and their family. The policy refers to the case conference review process, noting that the conference form and discussion points require a signature of acknowledgment from the resident or family members, and uploading to the electronic care record.

From the evidence reviewed it appears that Otumarama Care Home followed the policy guidelines, completed timely nursing assessments, and developed a personalised care plan in partnership with [Mrs A’s] EPOA, however, as identified by the provider there appear to be delays in meeting organisational processes in line with the PCCP policy at Whareama Care Home. As outlined in the PCCP policy, care plans provide guidance to the care team to ensure continuity of care delivery across shifts and are an essential part of the nursing process. Progress notes within the care record evidence care occurring and entries provide examples of person-centred care delivery at both care homes, however it is unclear how the RN team were able to safely lead and provide coordinated care without a current care management plan, in line with evidence-based nursing principles.

·     Departure from accepted practice: Significant

j) Whether the need for [Mrs A] to urgently go to the hospital if there was a suspicion that she did not ingest her cortisone tablet was well documented and communicated to staff? Was there an appropriate alert set up?

The care record reflects that [Mrs B] expressed concern to the RN team regarding the administration of Hydrocortisone medication and related care and safety responsibilities in [Month2]. An email dated 19 [Month2] was sent by the CM to the GP for clarification of a care pathway in the event that oral medication was not tolerated. Communication was received from the GP referring to the risk of an Addisonian crisis if Hydrocortisone was not administered. A GP letter dated 20 [Month2] stated that if [Mrs A] was unable to take oral hydrocortisone that she should have an immediate medical review and receive the medication intravenously. Alerts with this information were present on [Mrs A’s] prescription in Medimap, the electronic medication system, with instructions to “Take Hydrocortisone tablet with milk” and “If unable to take oral Hydrocortisone transfer immediately to ED (emergency department) to avoid Addisonian Crisis”. Medical notes state to contact the GP if [Mrs A] was unable to take oral hydrocortisone to arrange alternative administration. This information is reflected in the care plan (11) that states “[Mrs A] must have her Hydrocortisone doses at the precise times. Her daughter advises that if she is unable to take the hydrocortisone orally that she must go to ED to have it administered IV. She states that there is an alert on her hospital file for staff there to know what to give her”.

The provider has advised that the care teams were all aware of [Mrs A’s] allergy status, however it is unclear if they received any specific education regarding their clinical responsibilities. As identified, there is no evidence of care plan guidance commenced while [Mrs A] was resident at Whareama Care Home to support the RN and care team with safe decision-making.

From the evidence reviewed to respond to this question, it appears that safety alerts and relevant clinical guidance was in place while [Mrs A] was resident at Otumarama Care Home, however these documentation standards were not evidenced at Whareama Care Home. While alerts were noted in Medimap, medical notes and E’case information pages, there was no evidence of current care planning to guide [Mrs A’s] healthcare needs. This would be considered a deviation from safe clinical practice, care responsibilities and accepted documentation standards, and viewed similarly by my peers.

·     Departure from accepted practice: Significant

k) Please review the clinical notes and comment on whether the actions of the staff on 9 [Month5], where the complainant was concerned that [Mrs A] had vomited and therefore possibly not ingested her hydrocortisone tablet, were appropriate?

File information reflects that [Mrs B] expressed concern about unsupervised mealtimes, health presentation and safe medication administration to the duty RN on 9 [Month5], and questioned if [Mrs A] had received her prescribed dose of Hydrocortisone. Medication administration records 1–8 [Month5] show that [Mrs A] routinely received prescribed breakfast medications between 0804 and 0852hrs each day. Records show she received her prescribed dose, which included Hydrocortisone, at 0857hrs, on 9 [Month5]. The prescription shows that timing for the second dose of Hydrocortisone was ordered at “1300–1500hrs”. Medication administration records 1–8 [Month5] show this dose of Hydrocortisone was routinely given after 1400hrs, and that she received the charted dose at 1427hrs on 9 [Month5].

[Mrs B] has discussed delayed nursing assessment and interventions. A carer entry from the AM shift on 9 [Month5] reports that [Mrs A] had some discomfort from the morning, ate very little food and that the RN was informed. RN progress notes reflect [Mrs B’s] concern with [Mrs A’s] wellbeing, discuss RN consultation with the care team regarding accounts of vomiting, with evidence that vital signs were recorded, however there appear to be discrepancies in the completion of a holistic nursing assessment and recognition of resident decline.

As discussed in question (J) medication records had a safety alert to prompt RN actions regarding Hydrocortisone management, however it is unclear if the duty RN was familiar with [Mrs A’s] original care plan and associated interventions. Given [Mrs B’s] previous background and knowledge as [Mrs A’s] primary carer and her expressed concern regarding the possibility of a missed dose of hydrocortisone, it is unclear why the duty RN did not seek GP/NP guidance as outlined in [Mrs A’s] plan of care ([Month2]) or consult the on-call clinical lead for support, in line with organisational policy.

From the evidence reviewed to respond to this question it appears the care provided to [Mrs A] was below the minimum standard in the circumstances. While progress notes provide event comment, there is no evidence of risk assessment, supportive interventions, care collaboration or escalation which would be considered accepted practice in the circumstances.

·     Departure from accepted practice: Moderate to significant.

l) When [Mrs A] appeared to be deteriorating on 9 [Month5], were the actions of the staff appropriate? Were their “clinical incident/accidents sentinel events” policy and “clinical escalation” pathway documents adhered to?

Clinical file information reflects that a carer alerted an RN at 1535hrs that [Mrs A] was not responding verbally and sought support, which is in line with recommended practice for signs of acute deterioration, organisational policies, and procedures (HQSC, 2019). RN progress notes state that [Mrs A] appeared very pale, was breathing but was not responding to spoken word. It is unclear if the emergency bell was activated for team assistance, in line with incident management processes. There is no discussion of first aid principles applied or assessment of vital signs at this time.

Progress notes indicate that an ambulance was urgently called, and a second RN assisted in preparing transfer documentation. It is unclear why [Mrs A] was not transferred from the resident lounge directly to her bedroom for privacy, further nursing assessment and care at this time. Progress notes state that the RN returned to the lounge to record [Mrs A’s] vital signs at 1550hrs and found that [Mrs A] appeared to have passed away.

[Mrs A’s] Advance Care Directive form, 22 [Month3], elects that ‘in the event of gradual or sudden health deterioration, which is deemed irreversible, to be kept comfortable and … allow me to die naturally with dignity and without pain or distress’. Progress note timeframes indicate the event evolved quickly which can be challenging to coordinate. It appears the RN promptly sought paramedic and peer support, and file information indicates that a carer remained with [Mrs A] until her family could be present which shows respectful care.

The Incident/Accident and Sentinel Event policy that was in place at the time (March 2018–2020), included guidance for managing serious events and investigation process. It appears the RN team informed [Mrs A’s] EPOA, GP and care home leaders who commenced a significant event investigation. The policy states that a corrective action plan will be written, implemented, and evaluated until “closed”, with a requirement for post-event evaluation, however a completed corrective action plan outlining the agreed improvement steps was not submitted in the evidence bundle. The provider has advised that the adverse event investigation process undertaken at the time was not robust with no specific actions identified. The organisation’s clinical processes have reportedly been reviewed and the Clinical Escalation Pathway was implemented in May 2022, in response to learnings and improvement related to this complaint.

From the evidence reviewed to respond to this question I consider the care provided to [Mrs A] by the afternoon team on 9 [Month5] to be acceptable given the timeframe in the circumstances. It appears the team recognised signs of decline and acted in a timely way. There are identified opportunities for strengthening acute care decision-making, communication and end of life care processes which would be viewed similarly by my peers.

·     Departure from accepted practice: Mild to moderate

m) Please review any information regarding what education is provided for care staff and RNs surrounding acute incidents and medication management.

The Professional Development Policy and Procedure for Clinical Staff (2021) provides discussion of organisational responsibilities to education and training with a list of background documents. The supporting Education policy was not provided in the evidence bundle. The provider has submitted copies of orientation manuals for the clinical manager and carer roles only, which refer to Inservice education and training, and professional development opportunities, but there is limited discussion of specific nursing topics. The CM orientation manual outlines responsibilities for incident management but does not specifically discuss education and training opportunities for team roles. The document discusses sentinel event reporting and reporting steps, and relevant polices are listed in the orientation checklist. The manual provides a list of clinical competencies and comprehensions that qualified nurses are required to achieve annually, which includes Medication Management. The Medication Administration Comprehension RN/EN (2020) provides a quiz for nurses in partnership with the Medication Management policy (not submitted), with a requirement of a pass score of 80%. The CM orientation manual states that the CM is responsible for ensuring team competencies are assessed and recorded in relevant work records.

The provider response has discussed improvements to organisational policies, orientation processes and staff training days, and included an agenda of monthly clinical education sessions for 2022–2023. No supporting content was provided. Clinical topics listed include professional requirements for nurses, the code of conduct, professional boundaries, and direction and delegation, however there is no discussion of specific training provided regarding incident and medication management. The CM orientation book indicates these sessions are delivered online via the organisation’s intranet, however again topic content was not provided.

Based on the evidence reviewed I am unable to respond to this question as it appears that limited information has been submitted by the provider to inform further comment. The provider has referred to a lack of robustness in the sentinel event report process with no evidence of a corrective action plan at the time to identify improvement opportunities. Given the range of discussion points raised, I would also consider falls management, pain management, nutrition and hydration, weight management, nursing assessment, care planning and documentation standards, communication, and complaint management as relevant clinical topics for reflection and learning.

n) Please comment whether you consider the issues identified (above) to be systemic issues at Whareama and Otumarama or whether it was more attributable to an individual, or both?

From the information reviewed I consider the raised discussion points to be related to care home leadership, systems and processes in place at the time, which appear to have influenced the quality of care delivered to [Mrs A], and her whānau.

Clinical advice

I note that the events occurred during the COVID-19 pandemic period 2020–2022 and would like to acknowledge the challenges and distress caused to residents, family/whānau, care teams and health service providers during this time.

Based on this review I recommend the care home team complete additional education on communication with and about older people and their family/whānau, including strategies for ensuring changes in resident needs are safely documented and appropriately communicated to minimise the risk of a similar occurrence in the future. To support this approach, I recommend that the care home team complete the HDC online modules for further learning — https://www.hdc.org.nz/education/online-learning/.

Jane Ferreira, RN, PGDipHC, MHlth

Nurse Advisor (Aged Care)

Health and Disability Commissioner