Serious oversights in the care of a woman at a Summerset retirement village in Hamilton during the final months of her life have been uncovered following an investigation.
None of the nursing staff who worked in Summerset down the Lane is still employed by the retirement village, which has apologised to the woman's next of kin.
The woman stayed at the retirement village between late 2016 and early 2017 and had several wounds, including ulcers and skin tears, when she was admitted.
The Health and Disability Commissioner (HDC), who undertook the investigation, understood the woman required hospital-level care.
However, the management of her injuries at Summerset was found to be lacking in a report released by deputy commissioner Rose Wall.
It also found the woman's pain was poorly managed, that her nutritional intake declined, and there was a lack of oversight from senior staff over the care provided.
Oversights published in the HDC report include:
• A delay in seeking specialist advice;
• Timely and appropriate interventions;
• Inconsistent wound care documentation;
• And minimal pressure prevention strategies.
As a result of the investigation, Wall deemed Summerset to be in breach of the Code of Health and Disability Services Consumers' Rights.
"[The rest home] had a duty to provide [the woman] services with reasonable care and skill," Wall said.
"This included responsibility for the actions of its staff … and an organisational duty to facilitate the continuity of care."
Wall thought the report highlighted the need for nursing staff to be alert to changes in a resident's condition. An importance should also be emphasised on providers seeking specialist advice in a timely manner, effective communication, and completion of documentation to support appropriate care planning and interventions.
The deputy commissioner recommended Summerset do the following after her report:
• Apologise to the woman's "advocate" - which the retirement village says it has;
• Report back to the HDC on its Corrective Action Plan - which the retirement village says it has;
• To use the report as a basis for staff training;
• Provide training to staff on wound care, pressure area prevention, and pain management;
• And review it's wound management policy - which the retirement village says it has.
Subsequently, Summerset's general manager of operations Eleanor Young said in a statement they had accepted Wall's findings.
"We sincerely apologise for the distress caused over the treatment received while in our care and have apologised directly to the next of kin," Young said.
"We made a number of improvements following an internal investigation in 2017, including staff education and training on wound and pain management.
"We also introduced an electronic resident records system in 2017 to automatically alert staff to wound management tasks and follow-up."
Meanwhile, in October 2017, the Ministry of Health provided the care centre with a three-year certification with no adverse findings for wound care and pain management which indicated the importments were in evidence, Young said.