Hospital failed to devise care plan

An Auckland hospital for the elderly which prides itself on high-quality care failed to make a written plan on how staff would prevent a high-risk resident from developing pressure sores.

Many elderly people are at risk of pressure injuries or "bed sores" partly because of fragile skin.

Marie Dillon, aged 88, was assessed as being at high risk of pressure sores when she was admitted to Elizabeth Knox Home and Hospital in Epsom in July 2013. But staff did not fill out the facility's form for preventive measures.

Mrs Dillon developed a 2.5cm-wide pressure sore on her left heel in September 2013. It had a blackish crust, said her doctor, who noted a gradual improvement following daily dressings and the use of a cushioned booty and air pressure mattress. In a review of her care, he attributed the pressure wound to Mrs Dillon being unable to lie on her side in bed because of a leg brace.

She died the following month in Auckland City Hospital, of a clot in a lung artery, after being admitted with pneumonia and in acute respiratory distress.

One of her daughters, Marie Sanders, made a wide-ranging formal complaint about Elizabeth Knox. But she has approached the Herald to express disappointment that Deputy Health and Disability Commissioner Rose Wall has decided to take no further action beyond making recommendations to the home and notifying the Health Ministry of the complaint.

There is disagreement among Mrs Sanders and several of her sisters.

One, Cushla Dillon, said there were no problems with their mother's care at Elizabeth Knox, which was a "wonderful" place.

Ms Wall indicated in documents given to Mrs Sanders that she accepted the finding of her expert nursing adviser that the failure to make a note of pressure area prevention measures was a "moderate departure" from accepted standards. But overall the deputy commissioner was satisfied the care provided was of an "appropriate standard".

Mrs Dillon, who had several chronic health conditions, was living at a retirement village apartment when she fell and fractured her left leg. At Auckland City Hospital, a metal plate was implanted and an external thigh-to-ankle brace fitted. She was moved to Elizabeth Knox to complete her recovery.

Elizabeth Knox chief executive Jill Woodward acknowledged in a letter to the commissioner's office that not documenting pressure injury prevention measures was inadequate and the facility had not met its own standards.

She outlined six corrective actions that had been taken, including providing training for nurses and clinical leaders about adhering to policies and joining a transtasman auditing system that compares quality of care at aged care facilities.

Ms Woodward told the Herald: "We pride ourselves on giving the very best level of care that we can."

She said Elizabeth Knox had a low rate of pressure-area cases compared to other Auckland aged residential care providers.