Oceania Care Company Limited breaches the code for errors in the care of respite residents – 20HDC02116

Aged Care Commissioner Carolyn Cooper has found that Oceania Care Company Limited has breached consumer rights under the Code of Health and Disability Services for respite care provided to a resident.

The resident, a man in his 80s, had several medical conditions, including Parkinson’s disease, heart failure, poor hearing, blindness in one eye and recurrent transient ischemic attacks (TIAs). Although he was usually cared for at home, he entered respite care for a five-day stay at Victoria Place Rest Home and Hospital (VPRH), owned by Oceania Care Company Limited.

On his first night the man fell unnoticed, but no assessments were made and documentation was incomplete. Furthermore, VPRH staff did not adequately respond to his deteriorating condition after the fall.

On day three, at the insistence of the man’s whānau, an ambulance was called and the man was admitted to hospital, where scans showed further strokes. Unfortunately, his health continued to deteriorate and he passed away two weeks later.

Ms Cooper found that Oceania had breached Right 4 of the Code, which gives consumers the right to appropriate standards | Toeatikanga.

Right 4(4) gives consumers the right to services provided in a way that minimizes potential harm and optimizes their quality of life. Ms Cooper concluded that Oceania has failed to meet health and disability standards to minimize harm in several respects.

When the man entered respite care, no fall risk assessment was conducted. Instead, it was stated that he could walk with a mobility aid. Despite the fact that the man had previously been in respite care at VPRH, a new risk assessment should have been carried out.

“Given the likelihood of his condition deteriorating over time and the potential for changes in workforce, historical information was not sufficient,” Ms Cooper said.

Following the man’s fall and his subsequent shortness of breath, Oceania failed to provide services with reasonable care and skill, in breach of Right 4(1) of the Code.

Regardless of whether the fall was witnessed or not, a post-fall assessment should have been performed and neurological observations initiated. This did not happen and minimal follow-up testing was conducted regarding the man’s shortness of breath.

Oceania has also breached right 4(2) of the Record Keeping Code. Ms Cooper said the documentation system at VPRH did not meet Health and Disability Services (Core) standards which require organizations to ensure consumer information is uniquely identifiable, accurately recorded, current, confidential and accessible when required. Oceania acknowledged that the man’s clinical data did not meet its own standards of clinical practice.

Ms Cooper commented on the lack of respect shown by Oceania workers towards the man and his whānau. This included dismissing injuries after the fall, ignoring the letter from the man’s wife’s GP and calling an ambulance after the man’s daughter-in-law threatened to take him to hospital herself.

“While some of these incidents are disputed and, if they occurred, could be seen as the actions of individual employees, I believe that management must create a positive culture that puts the well-being of residents at its heart, and Oceania has not succeeded. ‘, said Mrs Kuiper.

A registered nurse also breached Right 4(1) of the Code for failing to provide services with reasonable care and skill. Ms Cooper said the nurse “had to take responsibility for her failures and the failures of some of her staff to provide the man with appropriate care.”

Ms. Cooper also made negative comments about two other registered nurses who provided care after the fall.

Oceania has made several changes since the complaint, which are detailed in the report.

Ms Cooper made several recommendations for Oceania and the three registered nurses in her report, including that they issue a formal apology to the man’s whānau for the failures in care.