Man’s family had to demand ambulance at Tokoroa rest home
Rest home staff didn’t call an ambulance for a patient until his daughter-in-law threatened to take him to hospital herself.
The man was in his 80s, had a multiple health conditions and was on a five-day respite care stint at Tokoroa’s Victoria Place Rest Home and Hospital (VPRH) in 2019.
He had an unwitnessed fall at the facility, his health went downhill and he died two weeks later.
Victoria Place, which is owned by Oceania Care Company Limited, has been found to have breached a health code and disrespected the man’s family.
Aged Care Commissioner Carolyn Cooper says Victoria Place did not undertake a falls risk assessment of the man after his fall.
He had medical conditions including Parkinson’s disease, heart failure, poor hearing, blindness in one eye and recurring mini strokes.
Victoria Place employees have also been accused of showing lack of respect to the man and his family - including being dismissive of injuries post fall, disregarding a GP letter presented by the man’s wife, and not initially calling an ambulance.
The fall happened on the man’s first night in care.
It was indicated he could walk with a mobility aid but Cooper said a new risk assessment should have been done, despite him having stayed there before.
He told his wife when she visited the next day, and she reports asking for a hospital transfer. Staff felt this wasn’t required.
On day three she showed staff a GP letter about calling an ambulance if he showed stroke symptoms, she said, but was brushed off - this was disputed.
Later that day she called her daughterin-law, who came and “told staff that if no ambulance was called, she would take Mr B in a wheelchair to the hospital herself”, the report says.
The man’s wife also recalled oxygen being brought in from the ambulance as care centre staff said theirs couldn’t be used.
The patient was “working quite hard to breathe... sweaty, pale, and hypertensive, with an irregular pulse”, ambulance records say.
He was alert and reported lower back pain. After an initial improvement in hospital, a further scan revealed strokes that occurred since his previous CT scan. He died two weeks later. Cooper found Oceania breached the code by failing to minimise harm “in several respects”.
A registered nurse breached Right 4(1) of the Code for failing to provide services with reasonable care and skill.
Cooper said the nurse needed to “take responsibility for her failures and the failures of several of her staff to provide appropriate care to the man”.
There was no post-fall assessment or neurological observations for the man,
Cooper said, and minimal follow-up on his shortness of breath. Cooper also made adverse comments about two other registered nurses who provided care post fall.
Oceania also breached Right 4(2) of the Code for record keeping and acknowledged the man’s clinical records did not meet its own standards.
It was recommended the staff involved in the man’s care “undertake training on falls management, communication with consumers, and record keeping”.
The three registered nurses in Cooper’s report were also asked to provide formal apologies to the man’s family.