The importance of critical thinking and the use of
initiative by registered nurses when responding to different
scenarios, and the vital role of communication was
highlighted in a decision by Deputy Commissioner Rose
Wall.
An elderly woman was admitted to a rest home
owned and operated by Oceania Care Company Ltd. (Oceania).
Following her admission, the woman did not receive her
regular medications, most notably insulin, and she died less
than 24 hours after her arrival at the facility.
In
her decision, Ms Wall found Oceania and two registered
nurses in breach of the Code of Health and Disability
Services Consumers’ Rights (the Code) for failing to
provide services to an elderly woman with reasonable care
and skill. She also made adverse comment about care provided
by two further registered nurses.
Ms Wall acknowledged
the significance of what transpired in this case, and the
dire consequences for the consumer and her family as a
result of serious shortcomings in her care.
“The care
provided to the woman fell short of acceptable standards in
a number of areas in a time frame of less than 24 hours. At
least three of the four nurses involved in her care failed
to fulfil their clinical responsibilities and adhere to
policies and procedures.
“People in an aged
residential care setting frequently present with multiple
comorbidities and complex health conditions, and often are
not in a position to advocate for themselves or alert others
to issues of concern.
“They are reliant on the health
professionals responsible for their immediate safety and
well-being. It was reasonable to assume that all those
health professionals involved in this woman’s brief
episode of care should have been competent to recognise and
manage her conditions.
“Diabetes is not uncommon – it
is a serious disease that affects many older adults,” says
Ms Wall.
This case highlights the importance of
accurate forward planning for new admissions, and of
vigilance when dealing with consumers who require their
medications in a timely manner.
The Health and
Disability Service Standards require organisations to ensure
consumers receive medicines in a safe and timely manner that
complies with current legislative requirements and safe
practice guidelines.
Ms Wall noted Oceania had
policies in place to manage medication for new admissions to
enable continuity of life-saving medications for new
admissions, and the woman’s admission assessment detailed
she was taking warfarin and insulin.
“I consider that
Oceania was on notice that the woman required potentially
life-saving medication and regular
monitoring.
“Despite that notice, and having policies
and procedures to manage this exact situation, the woman did
not receive a prescription or verbal order for life-saving
medications and, tragically, did not receive medications
that could have managed her blood-sugar levels and
ultimately prevented her death.
“While there is
individual accountability, Oceania must take responsibility
for failures at an organisational level,” says Ms
Wall.
Ms Wall made multiple recommendations to
Oceania, including that it review its policies and guidance
for staff, and processes for escalation and follow-up to GPs
where urgent medical review is requested. She also
recommended that Oceania and the four registered nurses each
write an apology to the woman’s family, and familiarise
themselves with the Ministry of Health publication
“Medicines care guides for residential aged care”
(2011).
Ms Wall further recommended the Nursing
Council of New Zealand consider whether a review of two of
the nurses’ competence is
warranted.
Notes
This case relates to a
complaint made to HDC in 2019. We aim to investigate
complaints as promptly as possible, while ensuring natural
justice and the interests of all the parties involved to
provide information, and respond to evidence put forward by
others is considered.
The full
report of this case can be viewed on HDC’s website –
see HDC’s ‘ Latest
Decisions‘.
Names have been removed from the
report to protect privacy of the individual involved in this
case. We anticipate that the Commissioner will name Te Whatu
Ora (previously DHBs) and public hospitals found in breach
of the Code unless it would not be in the public interest or
would unfairly compromise the privacy interests of an
individual provider or a consumer. HDC’s naming policy can
be found on our website here.
HDC
promotes and protects the rights of people using health and
disability services as set out in the Code
of Health and Disability Services Consumers’ Rights (the
Code).
HDC acknowledges the significant pressure the
health and disability system is currently under with limited
capacity to respond to the demands placed upon it. However,
notwithstanding these challenges, people’s rights under
the Code continue to
apply.
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