Rest home criticised over woman's care

A North Island rest home has been criticised for its care of an 87-year-old woman who suffered a series of falls and pressure sores and died soon afterwards.

Deputy Health and Disability Commissioner Theo Baker said, following her investigation of the 2011 case, that the New Vista Rest Home's management of the resident's medication and care planning and its communication with her were below the required standard.

The woman, whom Ms Baker names "Mrs A", fractured the neck of a thigh bone in a fall at home and had total-hip-replacement surgery. By the time she was discharged back home to the care of her daughter several weeks later, she had blisters on both heels and a reddening of the skin on the sacral area at the base of the back.

She had a fall at home and medical assessment led to her being admitted to the New Vista in Whanganui for short-term respite care.

More falls ensued, the last of which, at 4.45 on a Monday morning, resulted in her hitting her head on some drawers, causing a small cut. Later in the morning she felt sick and hot.

During the weekend, she had gone without her anti-anxiety medication because the home had run out. She called her daughter in a distressed state on the Saturday and the daughter phoned the home, but no action was taken to obtain a repeat prescription until the Monday.

By the time of the last fall, "Mrs A had extensive pressure sores on her sacral area and both heels," Ms Baker said. "Her legs and heels were bandaged and it was recorded that the sores on her heels were gangrenous."

Nursing notes recorded she was started on antibiotics and a drug to relieve oedema - fluid build-up - because of "infected wounds and oedema in legs".

The next day, a district nurse noted that "both of Mrs A's lower legs were leaking clear fluid and her fingers were cyanosed [had turned blue]".

She was taken to hospital, where staff queried whether she had suffered a stroke and recorded she was likely to have concussion. Community hospice care was arranged and she died at home a short time later.

Ms Baker said that at the rest home, Mrs A's care plan, an essential element of quality care, was incomplete.

"No skin integrity or pressure area risk assessment was made and, although Mrs A's heel pressure areas were recorded in the pain section, no pain intervention was planned."

Ms Baker said the primary responsibility for the failings lay with the rest home and she recommended it apologise to the woman's family for its breaches of the code of patients' rights, which it had done.

The home was now under a new management structure, had appointed an experienced clinical nurse leader and had made extensive changes to address the issues that had led to the complaint.

Ms Baker made "adverse comment" on the registered nurse who was the care manager at the time of Mrs A's case for omitting a medication check and over deficiencies in communication and care planning.

She also expressed concern about the DHB's care planning around pressure areas in the days immediately following Mrs A's hip surgery.

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