Care provided to elderly woman fell short of acceptable standards

The importance of critical thinking and the use of initiative by registered nurses when responding to different scenarios, and the vital role of communication was highlighted in a decision by Deputy Commissioner Rose Wall.

An elderly woman was admitted to a rest home owned and operated by Oceania Care Company Ltd. (Oceania). Following her admission, the woman did not receive her regular medications, most notably insulin, and she died less than 24 hours after her arrival at the facility.

In her decision, Ms Wall found Oceania and two registered nurses in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide services to an elderly woman with reasonable care and skill. She also made adverse comment about care provided by two further registered nurses.

Ms Wall acknowledged the significance of what transpired in this case, and the dire consequences for the consumer and her family as a result of serious shortcomings in her care.

"The care provided to the woman fell short of acceptable standards in a number of areas in a time frame of less than 24 hours. At least three of the four nurses involved in her care failed to fulfil their clinical responsibilities and adhere to policies and procedures.

"People in an aged residential care setting frequently present with multiple comorbidities and complex health conditions, and often are not in a position to advocate for themselves or alert others to issues of concern.

"They are reliant on the health professionals responsible for their immediate safety and well-being. It was reasonable to assume that all those health professionals involved in this woman’s brief episode of care should have been competent to recognise and manage her conditions.

"Diabetes is not uncommon - it is a serious disease that affects many older adults," says Ms Wall.

This case highlights the importance of accurate forward planning for new admissions, and of vigilance when dealing with consumers who require their medications in a timely manner.

The Health and Disability Service Standards require organisations to ensure consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.

Ms Wall noted Oceania had policies in place to manage medication for new admissions to enable continuity of life-saving medications for new admissions, and the woman’s admission assessment detailed she was taking warfarin and insulin.

"I consider that Oceania was on notice that the woman required potentially life-saving medication and regular monitoring.

"Despite that notice, and having policies and procedures to manage this exact situation, the woman did not receive a prescription or verbal order for life-saving medications and, tragically, did not receive medications that could have managed her blood-sugar levels and ultimately prevented her death.

"While there is individual accountability, Oceania must take responsibility for failures at an organisational level," says Ms Wall.

Ms Wall made multiple recommendations to Oceania, including that it review its policies and guidance for staff, and processes for escalation and follow-up to GPs where urgent medical review is requested. She also recommended that Oceania and the four registered nurses each write an apology to the woman’s family, and familiarise themselves with the Ministry of Health publication "Medicines care guides for residential aged care" (2011).

Ms Wall further recommended the Nursing Council of New Zealand consider whether a review of two of the nurses’ competence is warranted.