Elderly man waited days for adequate treatment for broken leg

An Invercargill retirement village has failed a man in its care after he was forced to wait days for adequate treatment of a broken leg, the deputy health and disability commissioner has found.

The man, aged in his 70s and a dementia patient at the Rowena Jackson Retirement Village in 2018, was agitated and complained of pain in his upper leg.

But he had to wait days for adequate treatment for what turned out to be a broken femur.

Deputy commissioner Rose Wall’s report, released yesterday, says a caregiver reported the man’s pain to the registered nurse. But the nurse failed to commence a pain assessment tool or pain observation chart.

The following day, the man deteriorated and continued to complain of pain in his leg.

A fax was sent to the GP for pain medication, and a second fax requested the GP review the man’s condition.

However, the GP did not receive the second fax and no-one at the village followed up with the GP.

As a result, the GP did not attend the retirement village that day.

It was not until the day after that the GP was contacted again.

The GP then reviewed the man and discovered he had not been weightbearing for two days and diagnosed him with a fractured femur.

The man was transferred to hospital via ambulance.

Upon arrival, the left femur fracture was confirmed and he was diagnosed with ‘‘left sided pneumonia’’.

On ‘‘29 month 1’’ he underwent a left hemiarthroplasty [surgical procedure that replaces one half of the hip joint] under general anaesthesia, but his condition deteriorated in the two days following surgery and he died on ‘‘8 month 2’’, the report says.

Wall found that Rowena Jackson Retirement Village did not provide appropriate care and services to the man following the discovery of his leg pain.

The retirement village was in breach of the Code of Health and Disability Services Consumers Rights for its failure in its care of the man.

‘‘My report highlights multiple staff failures to use an appropriate pain assessment tool and monitor his pain adequately,’’ Wall said.

‘‘There was also a lack of urgency in obtaining a GP review, no referral or attempt to transfer the man to hospital was made following the delayed GP review, and written communication with the man’s GP was inadequate,’’ she said.

Wall recommended the retirement village audit its compliance with the falls management plan and it use a new fax template and amended fax referral document.

The retirement village has apologised to the man’s family, the report says.

Cheyne Chalmers, chief operations officer of Ryman Healthcare which operates the Rowena Jackson Retirement Village, said it fully accepted the commission’s findings.

‘‘We have apologised to the family involved – we regret the pain and distress caused to our resident and his family and accept we should have done better. We are genuinely sorry for what happened, and lessons have been learned.’’

Ryman had the appropriate polices in place for his care, but policies were pointless unless they were followed, Chalmers said.

‘‘It is Ryman’s responsibility to support its staff to ensure they are aware of policies and that they comply. It is also Ryman’s responsibility to foster a culture of compliance.’’

Ryman had followed up on all the recommendations from the commission, including auditing communication with its GPs, and the health assessment template it used.

It had also carried out additional training in falls prevention, pain assessment, care planning and communication with allied health professionals.