Standard of respite care of elderly man with multiple health problems

Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in respite care provided to an elderly man.

An 80-year-old man who suffered from multiple health problems, including Alzheimer’s dementia with delirium, was admitted to the psychogeriatric unit of a rest home for a two-week period of respite care. The man’s stay involved periods of unsettledness, which included challenging behaviour, agitation, and refusing medication and cares. The man was restrained with a lap belt several times and the restraint policy and procedure were not followed. The man was manually assisted to make a bowel motion when this was not clinically indicated or consented to. The man’s diabetes was not monitored during his admission, and when the man was not eating, there was not a systematic evaluation of the reasons for this. Personal cares, particularly regarding oral care and showering, were lacking. The facility manager and the clinical nurse manager were both off site for much of the man’s stay.

Ms Wall considered that the rest home failed to provide services to the man with reasonable care and skill in a number of ways. The rest home had the responsibility to ensure that the man received care that was of an appropriate standard and complied with the Code. The man was a consumer with multiple comorbidities and challenging behaviours and he was temporarily moving into a respite care facility where he would be unfamiliar with staff and his surroundings. Ms Wall stated that in her view, these circumstances made the man particularly vulnerable. Ms Wall was critical of the rest home that there was not a clear assessment at the outset of the clinical and behavioural issues that could arise during the man’s respite stay, and that there was a lack of evaluation of the whole clinical picture of his declining health. Ms Wall considered that overall the care provided by the rest home to the man was not provided with reasonable care and skill.

The restraint coordinator, a registered nurse (RN), had a responsibility to ensure that the man received care that complied with the Code. Ms Wall was critical that he allowed restraint to be applied to the man in a manner that did not comply with policy, and allowed an invasive procedure to be performed by a healthcare assistant without clinical indication and without consent or consultation with the man’s family.

The facility manager had a responsibility to provide an appropriate standard of care to the man, even though she was not physically on site for much of his stay. Ms Wall considered the admission process for the man was suboptimal, and there was inadequate senior staffing oversight during the respite period. Accordingly, Ms Wall considered that the facility manager did not provide services to the man with reasonable care and skill.

Ms Wall recommended that the rest home provide further training for all staff on the NZS 8134.2.2008 Health and Disability Service Standard (restraint and minimisation and safe practice standards); undertake an audit of the restraint use consent forms; undertake a review of its processes in relation to respite assessment and care planning, documentation, medication management, and management of complex conditions; undertake a review of the staffing levels and skill base; update the client-initiated resuscitation form; update the resident register documentation; provide an update on the work that has been undertaken with the district health board to ensure that service provision requirements have been met; and provide a written apology to the man’s family.

Ms Wall also recommended that the registered nurse undertake training on informed consent and restraint minimisation and safe practice standards, and that the RN and facility manager both provide written apologies to the man’s family.