Deputy Health and Disability Commissioner Rose Wall says it is important rest homes have staff with adequate expertise and skill to support younger residents with chronic medical conditions and complex comorbidities.

Her comments come in the wake of a case brought to the Health & Disability Commission (HDC) involving a Bupa residential care facility’s care in 2014 of a resident who – in addition to other health issues – had multiple sclerosis and was diabetic.

Upon developing a pressure sore, a wound care plan was started for the resident. The resident’s GP assessed the wound and expected it to respond well to good nursing care. Over the next fortnight, nursing staff recorded the increasing deterioration in the wound, and in the woman’s general condition. However, no action was taken to refer the woman to a wound care specialist nurse or to seek a reassessment by her GP.

One day, nursing staff noted the wound had deteriorated again, along with the woman’s  general condition, but no further medical advice was sought. That day, the woman was administered zopiclone which she was prescribed for insomnia. Two days later, staff found the woman to be unresponsive. By the time her vital signs were taken in the early afternoon, she was acutely unwell. The woman was sent to hospital by ambulance and underwent urgent surgical debridement of the sacral pressure wound, but sadly died.

Following a formal complaint to the HDC and subsequent investigation, Ms Wall today released a report finding the Bupa rest home, clinical manager, unit coordinator and registered nurse in breach of the Code of Health and Disability Services Consumers’ Rights for failures in the resident’s care.

She considered that rest home staff failed to assess, think critically, and act appropriately in response to the woman’s deteriorating wound and general condition. Ms Wall was also critical of the clinical manager’s and unit coordinator’s lack of response to the woman’s wound deterioration and “very concerned” at the poor care provided by the woman’s allocated nurse in relation to wound management and the administration of zopiclone.

Ms Wall made several recommendations, including that the rest home update HDC on the finalisation and implementation of the policies regarding pressure injury prevention and management, and short term care plans; its implementation of the electronic medication management and electronic incident management systems; and the implementation of the proposed new role of roving clinical manager.

Bupa says it remains “deeply regretful” and has apologised for the distress caused to the family.

A spokesperson for Bupa says the case has resulted in “considerable reflection and review” within the company and they have worked to put better practices and policies in place for their residents, particularly in the area of wound management.

In the years since this issue occurred, Bupa has appointed a new leadership team and introduced a thorough training and education programme for all care staff around pressure injury prevention and management, including a new wound management policy.

“We realise that these improvement to practice in no way make up for the standard of care delivered, but we are taking all possible steps to eliminate the factors that contributed to the unacceptable level of care.”

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