Multiple Failures Identified in HDC Report

dementia

A report out from the Health & Disability Commissioner regarding the care provided to a woman while a resident at Radius Elloughton Gardens gives some answers to her daughter. The elderly dementia patient died shortly after her transfer to hospital. A complaint was filed with the Health and Disability Commissioner, who has released her decision and the "multiple failures" by Radius Elloughton Gardens.

It was determined that following the woman’s admission to Elloughton Gardens, staff did not undertake an interRAI assessment or implement an adequate care plan for food and nutrition after taking into account her dementia. Towards the end of her stay, staff failed to identify and respond to signs of dehydration and deterioration.

Before she was admitted to Radius, an assessment was due to be completed but a lot hadn't been done as she had been in hospital at the time. However, staff had recorded that she was "independent with eating and drinking once set up and given prompts", and could mobilise independently but "require[d] steady assistance ... to remain safe".

The DHB's progress notes at that time stated that she could "sometimes present resistant and a little agitated toward staff with food, fluid and medication".

"However, she is easily persuaded."

The woman's daughter told the commissioner that she had concerns about her mother's care about a month later when she believed she wasn't getting enough fluids.

The Deputy Commissioner found Radius Residential Care Limited (Radius) in breach of Right 4(1) of the Code. A number of failures in the services provided by Radius were identified, including the failure to undertake adequate care planning for food and nutrition in a timely manner, a failure by multiple staff to identify and respond to signs of dehydration and deterioration, and a failure to undertake a skin scraping for suspected scabies in a timely manner.

The Deputy Commissioner recommended that Radius provide a written apology to the woman’s family for the breach of the Code.

The Deputy Commissioner also recommended that Radius provide an update of its revised policies and procedures, report on the audits undertaken to monitor compliance with its Nutrition and Hydration policy, and use this case to provide continuing education to the nursing staff at its facilities.

Radius however stands by the level of care provided and have stated that although the woman refused food and fluids they had continued to offer both to her.

The report highlights the importance of adequate care planning and monitoring for patients in rest homes.