A Timaru rest home has been found in breach of the Code of Health and Disability Services Consumers’ Rights for failures in their care of a resident with dementia who later died.
Mrs A, who was in her 80s, had severe dementia and had been transferred to Radius Elloughton Gardens in 2018 following rehabilitation from a fall resulting in a fractured neck of the femur, Health and Disability Commissioner Rose Wall said today in a report released today.
In her report, Wall said that following the woman’s admission to the rest home, staff did not undertake a comprehensive clinical assessment or implement an adequate care plan for food and nutrition which took into account her dementia.
Towards the end of the woman’s stay, staff also failed to identify and respond to signs of dehydration and deterioration.
Mrs A was later transferred to a hospital, where she was found to be severely dehydrated. She was diagnosed with acute and chronic renal impairment and pneumonia. She died later that evening.
The resident's daughter told the Health and Disability Commissioner she was "deeply shocked and heartbroken" when she saw the “appalling condition” her mother was in by the time she was transferred to the hospital.
"I feel my mother did not receive adequate medical care, fluids and water intake when in isolation for nine days at Radius Elloughton," she said.
"Duty of care was clearly not shown by the four nurses while my mother was in isolation, particularly on my mother’s last day at Elloughton Gardens."
Wall found that there were multiple failures in their care, including a failure to undertake adequate care planning for food and nutrition in a timely manner; a failure of multiple staff to identify and respond to signs of dehydration and deterioration; and a failure to undertake a skin scraping for suspected scabies in a timely manner.
"It was the responsibility of the rest home provider to have in place adequate systems to ensure that staff provided the woman with care of an appropriate standard and that complied with the Code," Wall said.
"In my view, a number of aspects of the care provided to the woman were deficient, and the failures of multiple nursing staff involved in the woman’s care demonstrate a pattern of suboptimal care."
Radius said it was "upset to discover that [Mrs A’s] family were unhappy with the level of care provided to [Mrs A] at [Elloughton Gardens]".
"While Radius feels saddened for [Mrs A’s] family, it remains of the view that the care and services it provided to [Mrs A] was reasonable and appropriate."
Wall recommended that the rest home provider give an update on its revised policies and procedures, report on the audits undertaken to monitor compliance with its nutrition and hydration policy, and use the resident's case to provide continuing education to nursing staff at its facilities.
The rest home has provided a written apology to the woman’s family.
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