Rest home residents are dying from bed sores. Nicholas Jones finds the preventable tragedies reflect wider problems in a sector trusted with our most vulnerable.
Rosalie Cunningham played golf through her 70s but dementia stopped that and other more mundane activities.
After a pan caught fire, her stove fuse was removed by her daughter, Paula Sole, and a note left in its place.
"I knew Mum would ring someone to come fix it," Sole recalled. "So there was a note saying, 'My mother has dementia, so don't replace the fuse.'"
Her mother had home help and was visited by Sole twice daily. Things came to a head after a urinary tract infection worsened behaviour changes.
"When I arrived on a Saturday morning she was sitting there bright and perky saying, 'Oh, are we going out for lunch?' And she was sitting in poos and wees on the sofa and stinking to high heaven. She'd been there all night, because she was struggling at that stage to know what was day or night."
After a stay in hospital, Cunningham eventually moved to a rest home, where she lived for about three years.
She went downhill after fracturing a femur in a fall. Dementia meant she didn't know what to do with food or drink put in front of her, but carers assumed she wasn't hungry or thirsty.
She spent hours in a chair, but with no footrest her feet dangled and she slid down, causing shearing pressure that led to reddening of her lower back.
A special mattress topper to ease pressure helped but just as the wound began to mend it was taken away when another resident needed similar support. The incontinence meant she needed regular cleaning, and Sole said staff seemed to lack knowledge about how to wash her pressure ulcer.
Delicate skin broke down and became infected, leading to sepsis. Cunningham was in pain, unable to drink or eat and the infection worsened. Sole made the gut-wrenching decision to stop medication, and less than 24 hours later her mother died.
Sole didn't lodge a formal complaint over the 2012 death, partly because the rest home apologised. It has since changed ownership.
Just two years later another rest home resident died from a festering bedsore. Bupa NZ was strongly criticised in a Health and Disability Commissioner decision on the case, released last month.
Despite staff noticing a lower back ulcer getting worse, the woman (who wasn't named, along with the facility) wasn't referred to a wound care specialist nurse or GP. After being found unresponsive she was taken to hospital for urgent surgery, and later died of septic shock.
Jan Adams, Bupa NZ's managing director, said it was deeply regretful of the care provided, has apologised to the family and made changes since the 2014 death. These include a new leadership team, and an emphasis on pressure injury training.
Disconnected call bells and wandering residents
A Weekend Herald investigation into the country's 651 aged care facilities has found a litany of problems, many that come up again and again.
They include staffing levels so low that there is a risk to the safety of residents, no response when residents lose large amounts of weight – a common sign of serious illness – expired medication, disconnected call bells and alleged elder abuse.
Consumer and health advocates point the finger at years of Government inaction, and are pressing Health Minister David Clark to act.
Issues uncovered through Official Information Act requests and a review of more than 1000 audit reports include:
• Residents claiming intimidating caregivers would withhold medication or give it late as punishment. A resident at another facility was overheard saying, "please don't hit me" to a staffer.
• A Dunedin chef went to authorities, claiming his budget worked out to just $1.60 per resident, per meal. Residents were asking relatives to bring bread and fruit. Another facility repeated its menu over two days.
• Life-threatening shortfalls, including a dementia resident wandering away from a facility – next to a busy road and stream – six times in four weeks.
• Amid feedback on meals and activities in one facility's annual satisfaction survey, a resident with previous suicidal ideology wrote down that they wanted to die. "No care plan to manage this risk was documented," auditors recorded in 2016. "And no follow-up had occurred."
• Communication with families was also a problem. In one case, auditors couldn't find evidence a "not for resuscitation" status on a resident's file was discussed with family. Documentation relating to resuscitation wishes was confusing or incomplete at other facilities.
A preventable but widespread suffering
One of the most prevalent problems is treatment of the type of ulcer that killed Rosalie Cunningham – injuries that are mostly preventable.
In total, 14 per cent of homes – almost 100 facilities – had recent and significant shortfalls directly related to pressure injury and wound care.
Pressure injuries (also called bedsores or pressure ulcers) normally develop over bony parts of the body, or when medical equipment contacts skin. The elderly, particularly those with reduced mobility, are at higher risk.
Injuries are graded. Stage three ulcers reach the bottom layers of skin and may have a bad odour, and look like a crater. Stage four wounds expose muscle, tendon, or bone.
Since January 2016 – and in response to two deaths – the Ministry of Health has required rest homes to notify them of stage three and above wounds, through a special "section 31" process.
However, the Weekend Herald's investigation shows a number of facilities have failed to properly grade and treat injuries, or even identify them in the first place.
The latter includes New Plymouth's Chalmers Elderly Care. A visiting DHB clinical nurse raised the alarm after examining a woman with a lower back ulcer. She was told pressure mattresses were broken and unlikely to be replaced.
The nurse found stage three ulcers on each of the same resident's heels, which staff weren't aware of. "Neither had been treated…the resident was in pain," a summary document states.
Another Chalmers resident, supposed to be on bed rest for a fractured pelvis, was found by a nurse, wandering about and in pain. A special mat that would have prevented this was broken.
In April 2016 auditors went in. They learnt 33 staff had left in just 12 months, there was a lack of turning charts for immobile residents, and no evidence that staff received skin integrity training.
Chalmers is run by Presbyterian Support Central. Its chief executive Chris Graham says the organisation deeply regrets having let down some residents. He says problems have been addressed, including through staffing changes, and two successful audits have since been held.
Problems at other rest homes included no turning chart for a resident with a grade four pressure ulcer - a classification for wounds so deep that muscle, tendon and bone can be exposed.
Unsafe staffing levels and hungry residents
Rest home certification audits happen every 1-4 years, and a spot audit occurs around the middle of that period.
Auditors check a number of standards and criteria; those that are only partially attained are graded by potential risk – negligible, low, moderate, or high – and corrective actions are ordered, with a timeframe for completion.
The ministry says these don't indicate a failure, and most homes will have areas needing improvement.
The Weekend Herald has compiled moderate and high risk ratings in every audit published since 2016 – a total of 840 moderate and 35 high shortfalls across almost 300 facilities (45 per cent of all homes). From today, this information can be searched using a special online interactive.
A third of all rest homes have shortcomings related to resident care, including care plans not being updated or detailed enough to guide staff.
Thirty rest homes didn't respond adequately when residents experienced a big drop in weight, and 36 didn't follow up falls and head injuries with the needed neurological assessments. One resident later ended up in hospital.
One in 10 homes received a medium or high corrective action that directly addressed staffing levels, training or competence.
For example, Riverton's Longwood Rest Home was unable to find a registered nurse to cover all night shifts, and failed to notify the DHB when this happened.
Ohope Beach Care didn't always have staff in the rest home because they were based in the adjacent dementia unit, and staff at Ashburton's Princes Court Dementia Care worked double shifts so often that auditors judged residents' safety could be at risk.
Corrective actions for Longwood, Ohope Beach Care, Greendale and Princes Court Dementia Care have all been signed off.
Auditors following up 2015 complaints about Woodhaugh Rest Home, a stone's throw from Dunedin's Botanic Gardens, were told the clinical manager fainted from exhaustion and broke her pelvis. An anonymous phone call to the DHB claimed she had worked 80-hour weeks.
Residents said food often ran out, and some asked relatives to bring fruit and bread. Woodhaugh's former chef later contacted the DHB, documents reveal, claiming his food budget worked out to $5 per resident, per day.
Two years later another audit took place, and families reported residents being poorly groomed, unshaven and often not in their own clothes. One family member noticed bruises on a relative, which they weren't informed about.
Woodhaugh changed hands in October last year. New owner Yaroslav Divnov said a yet-to-be-published surveillance audit showed drastic improvements.
"I have addressed everything I could see wrong with the business since I took over. It all sounds awful, but I don't see any issues reoccurring."
Pressure on Government to act
Six years ago, then-Equal Employment Opportunities Commissioner Dr Judy McGregor went undercover as a rest home worker, and witnessed an "overwhelming culture of positive caring".
"The reliance of New Zealand, of all of us, on the emotional umbilical cord between women working as carers and the older people they care for at $13-$14 an hour is a form of modern-day slavery," McGregor wrote in the landmark Caring Counts report.
The work was a catalyst for a pay equity case involving Kristine Bartlett and other caregivers, which has already increased pay to $19-$23.50 an hour.
In November, McGregor's successor Dr Jackie Blue wrote to new Seniors Minister Tracey Martin, briefing her on the work of the "caring counts" coalition she heads, which includes unions, industry, Age Concern and Grey Power.
Voluntary guidelines set with the Ministry of Health in 2005 specified recommended safe rates of staffing, falls, weight loss, and pressure sores, including two hours of registered nurse time and 12 hours of caregiver time for every rest home resident a week.
McGregor's report recommended the standards be made compulsory as a "basic floor", and Blue's letter noted that had not been acted on. The coalition wants the standards reviewed (because residents now have higher needs), and then made compulsory.
Labour and the Green Party called for the same thing shortly before last year's election, after holding a joint inquiry into aged care with Grey Power. Another pledge was the establishment of an Office of the Aged Care Commissioner, and tasking it with investigating a government-backed "star rating" system for rest homes.
Health Minister David Clark said in a statement there were many good aged-care providers, but stories of poor care were too common.
"One way forward would be to review and update aged care standards and make them mandatory. That option is still on the table, as are other recommendations in the inquiry report which are currently being considered for future work programmes."
Clark said it was important to note NZ First wasn't part of the inquiry, and the recommendations aren't Government policy. NZ First policy is to "implement national standards for aged home care that are appropriately monitored and enforced".
"A constant rush"
More than 32,000 New Zealanders live in rest homes, a number projected to reach 58,000 by 2030. The average age for entering care is 84 – up from 75 just 10 years ago.
David Wait, NZ Nurses Organisation's industrial adviser on aged care, said audit reports didn't pick up crucial personal connections.
"It's important for people to have the dignity of being listened to, and have some time [with carers]. And that's what our members report that they don't have with residents. They are constantly rushing, they don't have time to sit and talk," Wait said.
"The profit motive, and with staffing being the highest cost to these providers, I think that without some mandatory minimums, [care shortfalls] are always going to happen."
Simon Wallace, chief executive of the NZ Aged Care Association, which represents 90 per cent of rest homes, acknowledged that for registered nurses "there is a struggle to balance their administrative tasks with the direct, on-the-floor care of residents".
"The sector funding has not kept pace with increased costs…this has put significant strain on individual facilities' abilities to provide optimal staffing, technological advancements, an expensive array of equipment, and meet rising resident and family expectations."
Despite that, Wallace said rest home care brought enormous benefits, including more sociability, independence and the chance to address issues such as pain and weight loss.
On the Weekend Herald's investigation, he said audits didn't always give the full picture. For example, a pressure ulcer could develop before a person moved into a home.
Emma Prestidge, the Ministry of Health's group manager of quality assurance and safety, supported that view. The ministry's own analysis showed improvements in the sector, with fewer moderate and high corrective actions.
"It is always distressing to see and hear complaints in this sector, but I think the vast majority of providers are doing a very good job. We have a very good framework."
A push to improve pressure ulcer care gathered pace in 2015 after two deaths were linked to the wounds, including the case recently addressed by the Health and Disability Commissioner.
There hadn't been deaths causally linked with pressure injuries since, Prestidge said, although it was a complex area, and not every death resulted in autopsies or coroner findings.
"You felt like you were saying the same thing over and over."
Since 2015, 161 rest home complaints received by the ministry have been substantiated. Issues included unexplained injuries, rough handling of residents, family communication, food quality, medication and pain management, and a strong smell of urine at facilities.
Paula Sole feels a number of smaller things contributed to her mother's death, including domestic care staff not being involved in care planning and review. For example, when her mother left her cup of tea untouched this wasn't passed up the chain, and she became dehydrated.
Sole often raised concerns about her mother's care, including the lack of foot support when she was sitting, which led to the pressure sore developing. However, she felt that brought its own risk of being labelled "that woman who always makes a problem".
"It might be alright for a week or so. And then it would go back. And you felt like you were saying the same thing, over and over."