Following a serious fall which left her with a broken leg and needing surgery, a private Bay of Plenty hospital and a nurse were found to have breached the health rights of an elderly woman in their care.
According to a Health and Disability Commission report ruling, the woman had to wait three days before anyone attended to her injury, and in the meantime had only been given bruise cream and paracetamol.
Deputy Health and Disability Commissioner Rose Wall made the ruling against Golden Pond Private Hospital in Whakatāne, and against a registered nurse who worked there, after the woman’s daughter complained about the incident, which happened in 2019.
The woman, aged in her 80s and with advanced dementia, was a highly vulnerable consumer who was unable to communicate or advocate for herself and was reliant on others to protect her and keep her safe, the report said. The woman fell when she was being transferred by a single healthcare assistant via a standing hoist.
The healthcare assistant informed a nurse about the incident at the time, but the nurse did not assess the woman for injury or keep clear and accurate records about the incident. Following her fall, the woman experienced pain and discomfort, and there were several signs she was deteriorating. Despite this, her injuries were not assessed for three days.
It was only when a doctor examined her three days after the fall, that it was found she had fractured her femur, the large thigh-bone at the top half of her leg. She was transferred to the hospital for surgery.
Wall considered there to be a pattern of poor care provided to the woman over a three-day period following a serious fall, non-compliance by staff with existing policies and procedures, and poor documentation and record-keeping.
She also found that the nurse did not provide the woman services with reasonable care and skill, as she failed to take appropriate action upon being informed of the incident, and her documentation was poor.
The Deputy Commissioner said there were also a number of inactions and/or failures by multiple staff members in providing care to the woman, and found the care breached the Code of Health and Disability Services Consumers’ Rights (the Code).
Wall said the nurse who had breached the code, and another nurse colleague, must be assessed for competency by the Nursing Council of New Zealand.
“Robust policies and procedures in an aged-care setting are basic and fundamental to ensure older people receive services appropriate to their needs. These are vital to ensure staff receive adequate guidance and support to provide safe and effective health services on a consistent basis,” said Wall.
A Ministry of Health certification audit was undertaken in March 2021 with no areas identified as requiring improvement. Golden Pond was found to be compliant with the Health and Disability Services Standards and was certified for a four-year term, ending June 2025.
Golden Pond is a private rest home and hospital. At the time of events, it had approximately 60 residents, some requiring residential care, but most requiring hospital-level of care.
