Disabled woman suffered burns and blisters
A severely disabled woman suffered burns and blisters on her thighs because her care facility did not have continence pads in her size, a health and disability commission investigation found.
St John of God Trust was found to have breached the health and disability services consumers’ rights code by failing to provide services with reasonable care and skill and in a manner that respected the woman’s dignity.
A community homes manager in charge at the time failed to seek clinical advice from a registered nurse, provide sufficient advice to staff and manage the facility’s continence products, deputy commissioner Rose Wall found.
The woman, in her 20s at the time, has spastic quadriplegia, a form of cerebral palsy that causes the loss of use of the whole body, meaning she is unable to walk and does not communicate verbally.
She is fed through a gastrostomy, or opening in her stomach, with a feeding device.
She had been a resident at the St John of God Hauora Trust house in Christchurch for seven years and required continence products all the time.
These were to be checked and changed regularly, but there was no specific advice on the size of her continence product or the timing of changes, the HDC report said.
About 3am on July 4, 2019 a staff member changed the woman into an XXL pad as there were none available in her size, a medium.
After lunch the same day staff did not check to see if the woman needed changing as supplies of continence products had not been delivered.
The delivery arrived at 2.45pm, but it was another four hours before she was changed.
While hoisting the woman into her bed about 7pm staff found her to be very wet, wearing the much larger continence product, and suffering ‘‘extensive burn/blister to both legs’’.
They advised the community homes manager by phone but were told not to send the woman to hospital or take photographs of the burns.
Two staff members told the commission the facility ‘‘regularly ran out of continence products for residents, and that this had been raised with the manager previously’’.
Another staff member noted in handover notes that evening that ‘‘the burns turned to blister and liquid [oozing]’’.
The woman’s mother was advised by email the following day that her daughter had some blisters as a result of having the wrong-sized continence product.
On July 7 a staff member said she could not get a GP appointment for the woman.
The same day the woman’s mother came to visit and, horrified by the blisters, called an ambulance. She was admitted to hospital on July 8 where she received treatment for the burns.
The woman’s mother told the HDC that nearly two years after the incident, her daughter was still having ongoing problems with her skin where the burns were sustained.
Her main concern was not so much about how the burns came about, but rather how her daughter was ‘‘left to suffer for so long’’.
St John of God Trust said in a statement there had been a ‘‘great deal of reflection by all staff involved’’.
‘‘Staff have been very concerned that due to a lapse in ensuring best practice [Ms A] received an injury which resulted in a decision being made to move [Ms A] to another facility . . .
‘‘We acknowledge and take full responsibility for the care [Ms A] received between 4–7 July 2019.’’
Since the investigation St John of God has ensured enrolled nurses act under the delegation of registered nurses and escalate changes in health status and concerns about a resident to a registered health provider.
A new fulltime registered nurse was appointed to the role of community homes manager in November 2019, with a fulltime enrolled nurse supporting the role.