Rest home found to have provided inadequate care
Calvary Hospital has been ordered to make a formal apology to the family of an elderly patient after it failed to provide her with adequate care.
Yesterday, Aged Care Commissioner Carolyn Cooper released her findings of an investigation into a 2018 case in which an elderly woman fell while being walked, despite instructions from her physiotherapist that she wasn’t able to.
The woman fractured her knee and hip and died soon after.
The coroner referred the case to the Health and Disability Commission in 2021, with concerns about the level of care she had received.
Cooper found that Calvary Hospital Southland Ltd had breached the Code of Health and Disability Services Consumers’ Rights for hospital-level care provided to a resident.
“In my view, the overall co-ordination of the woman’s care between staff members at Calvary in relation to her mobility was inadequate,” she said.
Calvary Hospital has been approached for comment.
The elderly patient had multiple co-morbidities and her mobility had been declining in the years leading up to the fall, Cooper said. The physiotherapist documented her mobility needs, but other staff working with her failed to notice when these had been changed or amended her charts.
While the physiotherapist had noted that she could not be mobilised, the fall happened while two staff members were helping her to the bathroom with a mobility belt and a walking frame.
She was assessed but Cooper did not feel the fall or assessment were adequately documented.
When she later complained of pain that could not be treated by three doses of pain medication — including morphine — she was transferred to hospital where her fractures were discovered through X-rays.
The woman was deemed unfit for surgery because of her co-morbidities and was referred for palliative care.
She died two days after her fall, and the case was immediately referred to police and the coroner.
Cooper raised concerns about oversight and the standard of documentation at the rest home. But she acknowledged that it had since conducted an internal investigation into the case and made improvements.
This includes clear explanations of patients’ mobility needs on boards above their beds, along with a whiteboard in the nurses offices. Calvary has bought software so any staff member can notify nurses of changes to a patient’s care and introduced a group strength and balance class for residents.
The hospital told the aged care commission that by December 2023, 43% of its staff had completed training around supporting people to move while all had completed a training module called “Falls: Balancing risk”.
With this in mind, Cooper’s recommendations for Calvary were that it provide a formal apology to the woman’s family and educate and train its staff on handovers and co-ordination of care.
Cooper expressed her sincere condolences to the woman’s family for their loss.