Rest home gives elderly resident another's medicine, wrong dose of her own

A rest home breached the code of health and disability consumers' rights in giving an elderly resident the wrong medication on two separate occasions, the Deputy Health and Disability Commissioner has found.


The woman in her seventies was a rest-home level resident at Aria Bay Senior Living Limited at the time of the events in 2016.

On the first occasion on 16 May 2016 she was given another resident's medication, and on the second she was given an incorrect dosage of her prescribed medicine warfarin over a two-day period, June 4 and 5. 

On both occasions the caregivers who administered the medicine did not follow the rest home’s Medication Management Guidelines, Deputy Health and Disability Commissioner Rose Wall said in releasing her report today.

She found the rest home in breach of the Code of Health and Disability Services Consumers’ Rights for failing to provide a resident with an appropriate standard of care.

"There were a number of failings with regard to the management of medication and the subsequent care provided," said Ms Wall. 

She said the rest home failed to ensure staff followed good medication administration practices or their internal guidelines and that it failed to provide adequate oversight to ensure that staff followed relevant professional standards. 

She also found it did not have adequate systems and processes in place to prevent medication errors from occurring or re-occurring.

"All medication should be administered correctly. However, it is particularly significant in circumstances where rest homes are using caregivers to give medications such as warfarin where both the correct timing and correct dosage are highly important to the wellbeing of the person receiving that medication," Ms Wall said.

Ms Wall recommended that the rest home provide the woman’s family with a written apology. She also recommended the rest home provide the Health and Disability Commission with an update on changes put in place following the medication errors and on the home’s training and requirements for ongoing medication competency.

She further recommended the rest home obtain an independent audit of the frequency and nature of medication errors over the previous six months, and provide a report on the impact of any medication errors and the steps taken to prevent further errors from occurring.