A woman died a day after arriving at the nursing home, without medicine
An elderly woman died less than 24 hours after arriving at a nursing home, having not received her usual medication.
And four nurses involved in his care have come under fire from the deputy health and disability commissioner.
It comes three years after a complaint was made to the Health and Disability Commission (HDC) after the woman died shortly after being admitted to a nursing home run by Oceania Care Company Ltd.
The woman, who suffered from diabetes, was found not to have received her usual medications, including insulin, and died 24 hours after arriving at the facility.
The HDC found that two nurses and the Oceania Nursing Home itself breached the Health Services and Disability Consumer Rights Code for failing to provide the woman with reasonable care and skill.
Two other nurses were also mentioned in the decision.
“The woman’s care fell short of acceptable standards in a number of areas in less than 24 hours,” HDC Deputy Commissioner Rose Wall said.
“At least three of the four nurses involved in his care failed to fulfill their clinical responsibilities and did not follow policies and procedures.
“Elderly people in an aged care facility frequently present with multiple comorbidities and complex health conditions, and are often unable to advocate for themselves or alert others to issues of concern,
“It was reasonable to assume that all healthcare professionals involved in this woman’s brief episode of care should have been competent to recognize and manage her conditions,” she said.
Oceania has policies in place to ensure that all medications for new admissions are properly managed.
During the woman’s admission assessment, it was made clear that she was receiving warfarin and insulin, but was not given potentially life-saving drugs when she needed them.
“Despite this notice and the policies and procedures to manage this exact situation, the woman was not given a prescription or verbal order for life-saving medication and, tragically, was not given medication that could have managed her blood sugar levels. and ultimately prevented his death,” Rose Wall said.
“While there is individual responsibility, Oceania must take responsibility for failures at the organizational level.”
The HDC recommended Oceania review its guidelines and policies for staff and suggested follow-ups for GPs when an urgent medical examination is requested.
She also took this case as an example to emphasize the importance of anticipating new admissions.
Wall suggested that Oceania and the four nurses involved write letters of apology to the woman’s family.
She also recommended that the Nursing Council consider whether two of the nurses should have their skills assessed.