HDC slates rest home for failure to give adequate care to patient

A Taranaki rest home has been advised its staff require further education in care planning after a patient developed sepsis and died.

In a report released by Deputy Health and Disability Commissioner Rose Wall on Monday, Ultimate Care Rhapsody in New Plymouth, operated by The Ultimate Care Group Limited, was found in breach of the Code of Health and Disability Services Consumers’ Rights for failures in the care provided to an elderly woman.

Staff at the rest home were concerned the woman required a higher level of care, due to her medical problems and assistance requirements. However, they did not take steps to initiate a change.

The woman’s condition deteriorated while at the rest home in March, 2019, and after seven days she was transferred back to hospital, where she was diagnosed with sepsis secondary to cellulitis and died the following day.

In the report, Wall said there were serious issues with the planning of the woman’s care and attributed these to the rest home operator.

She found the woman did not have a clear initial care plan to guide nursing staff in providing co-ordinated care in light of her multiple medical problems; no steps were taken to have the woman reassessed for a higher level of care; and staff were not proactive in obtaining the discharge summary or assessment from the Taranaki District Health Board (TDHB).

‘‘Multiple nursing and caregiving staff were involved in [the woman’s] care.

‘‘Overall, I consider that [the operator] holds primary responsibility at a systems level for the poor standard of care provided.’’

Wall recommended the rest home operator arrange further education for its staff on initial assessment and care planning, decision-making and early intervention for deteriorating patients, and management of cellulitis.

She also recommended the rest home use a standard form to document handovers from the DHB, and take steps to ensure its staff were clear on the process required for timely reassessment of a resident if a higher level of care was needed. It was also recommended the rest home review its policies and procedures around managing a resident who requires a higher level of care, and provide an apology to the woman’s family.

The Ultimate Care Group Limited director of nursing and wellness, Carole Koffes, said the company always took complaints very seriously and had apologised unreservedly to the complainants.

‘‘We have all moved forward since then. We always ensure that we follow the recommendations to make improvements along the way.’’