Rest home criticised for patient’s poor care
A man died of septicaemia and facial cellulitis in hospital after staff from a North Canterbury rest home failed to respond properly to the man’s deteriorating condition, the Health and Disability Commission (HDC) has found.
Ultimate Care Karadean Court in Oxford was ordered to apologise to the man’s family, provide training to its staff, conduct an audit, and review staffing levels.
The man, in his 80s, had been admitted to the facility for hospital-level care six years ago. His health deteriorated during his stay, requiring interventions to manage his continence, hydration, medication, diabetes, podiatry and pain, the report said.
Deputy Health and Disability Commissioner Rose Wall said multiple staff had failed to pay attention and respond to the man’s deteriorating condition. Clinical managers had failed to provide proper oversight.
He was eventually transferred to hospital after two unsuccessful attempts to administer antibiotics. The patient died as a result of septicaemia and facial cellulitis.
Wall found that the man’s continence care was not properly reviewed; his podiatry reviews were not arranged for him; his diabetes was not adequately monitored; and his pain relief was not properly managed.
She criticised the inaccurate recording of the man’s wound care documentation and monitoring of the man’s pressure wounds, the failure to seek specialist advice in a timely manner, and the insufficient number of registered nurses available to provide oversight to junior staff. ‘‘I consider that deficiencies in the care provided by multiple staff represent systemic issues at [the facility],’’ she said.
She recommended Karadean give training to its staff on pressure area prevention, pain management, and oversight by the clinical manager. She also recommended it should audit compliance with policies developed in response to the complaint; review its staffing levels, induction and training programme, and equipment and supplies; and provide a formal written apology to the man’s family.