Rest home staff admit to ‘dropping the ball’ after death

A grieving daughter says she never got the chance to get her dad the critical care he needed because rest home staff kept her in the dark.

In the two months that led to her dad’s death, he had two falls and developed pressure injuries which were not properly documented and his family weren’t told about.

Yesterday, the rest home — which has not been named for privacy reasons — has been censured for failures to manage its care for the man in his 80s, a Health and Disability Commission decision revealed.

“Dad’s health requirements were far from maintained, his care was suboptimal as well as the communication between staff and management, also withholding of information to our family,” the daughter — who has not been named — said in the report.

A nurse who worked at the rest home acknowledged “there was a gap in communication with the family and said it was a situation of “dropping the ball”.

The HDC’s investigation found during two months in 2017 the man had two falls and developed pressure injuries which were not properly documented and his family weren’t told about. When the man was transferred to hospital level care, the rest home failed to document the extent of the pressure injuries to the new

Dad’s health requirements were far from maintained, his care was suboptimal. Daughter

provider.

Deputy Health and Disability Commissioner Rose Wall was critical of the rest home for failing to provide services to the man with reasonable care and skill.

Wall highlighted the importance of providers communicating effectively with one another and with the patient’s family, and of ensuring that clinical assessments and care plans were comprehensive and actioned.

It’s critical that documentation was completed to a good standard to support care and decision-making, including on the transfer of care to another provider, Wall said.

The daughter believed failures at the rest home caused her father’s “health and wellbeing to plummet dramatically over this period of time and cause his unnecessary demise”.

Wall noted that the man’s family were very involved in his care and would have expected pertinent information to be conveyed to them.

“I consider that information pertaining to a change in health condition, such as falls and pressure areas, is significant, and information that a family would expect to receive. I am critical that this did not occur”.

Wall recommended the rest home apologise to the man’s family, which has been done.

She also suggested the rest home consider gaining access to a more specialised level of nursing, clarify guidelines for accessing specialist advice, schedule regular and ongoing education sessions on specified topics and report back to HDC on the effectiveness of these changes and the results of audits in relation to the changes.