Oceania care company has been found in breach of the Code of Health and Disability Services Consumers' Rights for failing to provide adequate respite care for a man in his 80s who died.
Aged Care Commissioner Carolyn Cooper found Oceania Care Company Limited in breach in a report released on Monday.
The man, referred to as Mr B, was in his 80s and had several medical conditions, including Parkinson's disease, heart failure, poor hearing, blindness in one eye and recurring TIAs (transient ischaemic attacks - mini-strokes).
He was usually cared for at home but in 2019 he was moved into respite care at Victoria Place Rest Home and Hosptial (owned by Oceania) for five days.
On his first night, Mr B suffered an unwitnessed fall; however, Commissioner Cooper said no assessments were undertaken and documentation was incomplete. In addition, his deteriorating condition post-fall was not adequately responded to by employees.
In the report, it says Mr B's wife Mrs B visited him the next day and he told her "I have had the most terrible night of my life".
According to Mrs B, her husband needed to use the bathroom in the night but could not find the call bell and ended up getting up as he was desperate. He then groped around in the dark and fell. He told his wife he did not know how long he lay on the floor but eventually, he pulled himself up onto the bed and found that he had wet himself.
According to the rest home records Mr B slept well and there were no concerns. Mrs B said she told a registered nurse about his fall, who said it was "unwitnessed". Mrs B then pointed out Mr B had bruising and carpet graze marks but the nurse replied, "We don’t know that he has fallen. He could have just bumped into a doorway".
The nurse told the Health and Disability Commission she could not recall any conversation to this effect and said that she would not have spoken this way to Mrs B. However, she apologised if she had spoken this way.
The staff did not complete an accident report or notify the GP and said this was because there was no evidence Mr B had fallen and he had been checked regularly throughout the night.
Mrs B said after the fall her husband was in pain and not eating well so she asked he be transferred to hospital, but one of the nurses involved said he did not demonstrate a need to be hospitalised.
The nurses involved said they discussed their assessment with Mrs B and she seemed to understand. Meanwhile, Oceania said Mrs B said she believed her husband had suffered a transient ischemic attack but denied she asked for him to be hospitalised. Instead, they said she requested they contact the GP – which was not done.
On the evening of day two Mr B was breathless and had a raspy voice. He was told to sit upright in bed but there is no record of any follow-up assessment afterwards. The nurse who told him to sit up said once he did, he was settled and "I did not feel that any further assessment was required".
On day three, Mrs B said when she visited he was "curled up in bed in a fetal position". She said he was slurring and told her he had "had a terrible pain in his lower back, and it felt as if some vital organ had been injured".
Mrs B said she told his nurses he needed help and one replied "Oh, I’ll give him an anti-depressant to calm him down". The nurse denies saying that and the other nurse present said they had no recollection of that being said.
Mrs B and her daughter-in-law eventually asked for an ambulance to be called which was discussed among staff. Mrs B said her daughter-in-law eventually said if an ambulance wasn't called she would take him to hospital herself.
An ambulance was called and he was admitted to hospital where scans showed new strokes. Unfortunately, his health continued to decline, and he died two weeks later.
Cooper found Oceania breached Right 4 of the Code which gives consumers the right to appropriate standards | Tuatikanga.
Right 4(4) gives consumers the right to services provided in a manner that minimises potential harm and optimises their quality of life.
Commissioner Cooper concluded Oceania failed to comply with the Health and Disability (Core) Standards to minimise harm in several respects.
When Mr B entered respite care, no falls risk assessment was undertaken. Instead, it was indicated that he could walk with a mobility aid. Despite Mr B having stayed in respite care previously at the same rest home, a new risk assessment should have been done, Cooper said.
"Given the likelihood of his condition deteriorating over time and the potential for workforce personnel changes, historic information was not sufficient," she said.
The Commissioner said following Mr B's fall and his subsequent breathlessness, Oceania failed to provide services with reasonable care and skill, which breached Right 4(1) of the Code.
"Regardless of whether the fall was witnessed or not, a post-fall assessment should have been undertaken and neurological observations commenced," she said. "This did not occur and there was minimal follow-up monitoring in relation to the man's shortness of breath."
Oceania also breached Right 4(2) of the Code for record keeping. Cooper said the documentation system did not meet the Health and Disability Services (Core) standards which require that organisations ensure consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required.
Oceania acknowledged Mr B's clinical records did not meet its own standards of clinical practice.
Cooper said there was a lack of respect shown to Mr B and his whānau by Oceania employees. This included being dismissive of injuries post-fall, disregarding a letter from the GP presented by the man's wife and only calling an ambulance after the man's daughter-in-law threatened to drive him to hospital herself.
"Although some of these incidents are disputed, and, if they occurred, could be seen to be the actions of individual staff, my view is that management should set a positive culture with residents' wellbeing at the centre, and Oceania failed to do so," Cooper said.
A registered nurse also breached Right 4(1) of the Code for failing to provide services with reasonable care and skill. Cooper said the nurse needed to, "take responsibility for her failures and the failures of several of her staff to provide appropriate care to the man."
The Commissioner also made adverse comments about two other registered nurses who provided care post-fall.
Oceania has made several changes since the complaint including employing a new nurse practitioner, a new client management system has been implemented, professional development for nurses, extra training and several reviews of processes.
Cooper made several recommendations for Oceania and the three registered nurses in her report, including that they provide formal apologies to the man's whānau for the failures in care.
Director of Clinical and Care Services at Oceania Shirley Ross said their condolences and sympathy are with the man, his family, and loved ones.
"Oceania has carefully listened to, and implemented, all of the HDC's recommendations, including conducting an independent audit at Victoria Place Care Centre to establish how this occurred," Ross said.
"The results confirm that this was an independent incident and not a reflection of the wider culture.
"The staff directly involved in this case, who are still employed with Oceania, have received additional training to ensure that all residents are provided with services of the highest possible standard."
