Aged Care Commissioner Carolyn Cooper strongly criticised a care home in Tauranga following a distressing incident involving a dementia patient who assaulted another resident as he lay unconscious and dying. The incident occurred at Radius Residential Care in Althorp in early 2019, where both men resided in the specialist dementia unit.
According to the report issued by the Commissioner, Radius Althorp failed to implement effective measures to safeguard the vulnerable resident from harm posed by the other patient. As a result, the care home breached the Code of Health and Disability Services Consumers' Rights.
The complaint that shed light on this incident was made by the daughter of the resident who tragically suffered the assault. In her statement, Commissioner Cooper revealed that the complaint raised several alarming aspects of the resident's care and protection.
"The overall deficiencies in the end-of-life care provided to this man, the inadequate documentation and staffing levels at Radius Althorp, and the inadequate communication with the man's family demonstrate a pattern of suboptimal care and a lack of critical thinking from Radius Althorp staff members," said Cooper in her assessment.
The reported incident was not an isolated occurrence but rather the culmination of a series of sometimes violent altercations that took place over two months, ultimately ending in the resident's death.
The commission's report uncovered the fact that the care home staff had failed to devise a clear strategy to manage the escalating behaviours exhibited by the patient towards the vulnerable resident. Just days before the resident's demise, family members were present when the patient attempted to force his way into the room, prompting distressing scenes.
One family member shared their experience: "I was pushing the bedside emergency button on a lead beside Dad's bed. It didn't appear to work, as nobody came for what seemed an age, and he managed to force his way past as we tried holding the door closed. He was yelling that he was going to spit in our faces."
Concerned for the resident's safety, family members stayed overnight at the care home for the next two nights. Tragically, the following morning, the patient again entered the resident's room, attempting to wake him by shaking him forcefully from his bed. Regrettably, the resident received a blow to the back of his head.
Multiple staff members had to intervene to protect the resident, who unfortunately did not regain consciousness and passed away later that afternoon. An autopsy report cited pneumonia as the primary cause of death, with underlying cardiovascular disease and pancreatic cancer as contributing factors.
At the time of the final incident, only one registered nurse and four healthcare assistants were assigned to cover the 58 dementia care beds in the facility. An internal report by Radius acknowledged that staffing levels in the dementia unit were inadequate.
Furthermore, the commission's report highlighted the poor quality, incomplete, and insufficient documentation in the resident's clinical notes, including care plans, progress notes, and charts.
Another concern revealed by the report was the failure to conduct key assessments that would have identified the resident's transition into the end-of-life stage, potentially warranting his removal from the dementia care level. Additionally, communication with the resident's family was deemed lacking in transparency during the days leading up to and immediately following his death.
In light of the findings, Commissioner Cooper recommended that Radius Althorp issue an apology to the deceased resident's family and implement various changes identified in an internal review conducted by the care home. These changes included increasing staffing levels to ensure regular checks on patients and implementing additional training on incident and accident reporting.
These measures aimed to rectify the deficiencies in care, enhance documentation practices, and improve communication with families.
