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HEALTH AND DISABILITY COMMISSIONER CRITICISES POOR MANAGEMENT IN REST HOMES
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In four recent decisions, the Health and Disability Commissioner (HDC) has highlighted concerns about poor management of care for patients and residents of rest homes.

The key messages from the HDC that can be derived from these decisions, is that rest home policies should be continually updated, with emphasis put on the importance of staff to comply. Observation notes should be completed frequently with as much detail as possible, as these notes are a vital form of communication for the patients’ GPs to assess the patients’ changing conditions. Further, communication with the patients’ families are equally as important, to ensure that decisions are made in the best interests of the patients.

In the following cases, the HDC made recommendations for the rest homes to provide its staff with further education and training to ensure compliance.

The first decision concerned a 77 year old woman, Mrs A, who required hospital-level rest home care. She suffered from lymphoma that began as scaly, itchy, patches on the skin and also had lung cancer.

Mrs A’s skin condition was deteriorating, staff noticed blood on her bed linen, and she reported experiencing pain during personal cares. Mrs A was prescribed codeine for pain relief on an as needed (PRN) basis. Mrs A had a pain care plan but it was not updated in response to her changing condition.

Five days later, the clinical manager at the rest home commenced Mrs A on an hourly pain assessment tool and also sent a facsimile to Mrs A’s GP regarding Mrs A’s pain levels. The hourly pain assessment tool was filled in by rest home staff between 3pm and 8pm for one day, and was not filled in hourly after that.

The following day, staff at the rest home contacted the GP again with concerns about Mrs A’s skin condition and pain levels. The GP reviewed Mrs A and liaised with the public hospital for Mrs A to be admitted that day. Mrs A was given palliative care in hospital and passed away.

The HDC found that the rest home breached the Code of Health and Disability Services Consumers’ Rights (the Code), due to inadequate pain management of Mrs A. In doing so, it had failed to provide services to Mrs A with reasonable care and skill Mrs A’s pain care plan was not updated as her condition deteriorated, and evaluation of the effectiveness of PRN codeine was not recorded as required. The HDC also found that the rest home’s staff did not respond promptly and should have contacted her GP earlier. There was insufficient record of communications with family members of Mrs A, and the evaluation of the effectiveness of PRN codeine was not recorded, as required by the rest home’s policy.

Another decision concerned a 77 year old man, Mr B, who was admitted to a rest home for one week of respite care. Mr B had been diagnosed with castrate resistant metastatic prostate cancer, and had a long-term, urethral catheter in situ.

Prior to admission, staff from Needs Assessment and Support Coordination gave information to the rest home to inform it of Mr B’s ongoing issues with his catheter blocking, which would require hospital-level care.

Mr B complained of pain, was vomiting, and refused dinner and drank minimal fluids. Mr B’s daughter took him to hospital where he was diagnosed with acute kidney injury, bladder obstruction, and dehydration.

The HDC found that the rest home breached the Code, by failing to ensure that Mr B received services of an appropriate standard while at the rest home. These failures included:

  • lack of updating appropriate plans on admission to manage the regular and known problem of Mr B’s catheter blocking;
  • bladder irrigation was performed several times without first seeking medical advice, as required by the rest home’s policy;
  • Mr B’s catheter was removed without seeking medical advice, and he was not recatheterised promptly; and
  • no formal fluid balance chart was commenced and the monitoring of Mr B’s fluid balance was infrequent and inadequate. 
  • A third decision involved a man in his seventies, Mr C, who had an intellectual disability and diabetes, and resided in a rest home. In late 2013, Mr C’s resuscitation status had been discussed with this GP, who was recorded as stating that Mr C was to have active resuscitation.


A nurse noticed Mr C’s breathing was laboured and his skin was clammy. She gave Mr C a paracetamol elixir, and sat with him for approximately 20 minutes, at which point she believed he appeared more settled and less agitated. The nurse then saw Mr C’s legs rise and gently fall and noted that he appeared to have stopped breathing. The nurse checked Mr C’s pulse and recognised that he had died. The nurse did not commence CPR.

The HDC made adverse comment on Mr C’s resuscitation status. The rest home had in place a resuscitation policy that stated clearly if a resident had not been recorded as ‘not for resuscitation’, active resuscitation should be provided.

The HDC was also concerned by the rest home’s general manager’s statement that while the GP felt that Mr C should have an active resuscitation status, Mr C was unable to participate in the decision ‘due to probably lack of capacity’, and that his family were also not involved in the decision-making process. The HDC was also concerned by the general manager’s statement that Mr C’s ‘quality of life had become compromised to a point where he was not enjoying much in life’, and that ‘there comes a time to die and our suffering be eased.’

The HDC commented that it is not the role of staff of the rest home to reach such a conclusion. Mr C’s GP had determined that it was in Mr C’s best interest to receive active resuscitation. Had the staff had concerns about the GP’s medical assessment, it would have been appropriate to discuss the concerns with a medical officer during Mr C’s periodic medical examinations.

The final decision involved a 78 year old woman, Mrs D, with high blood pressure, type 2 diabetes, osteoarthritis of her knees, dementia, high cholesterol, and incontinence. Mrs D was a resident at a rest home and was taking simvastatin for her high cholesterol.

In 2011, Mrs D was prescribed ketoconazole for a severe fungal rash. Despite the potential for adverse interaction between ketoconazole and simvastatin, and the high risk of causing liver injury, Mrs D’s GP did not discuss the risks of ketoconazole with Mrs D or her family.

Mrs D was taken to a public hospital due to a fall. The use of ketoconazole was not documented, and therefore staff at the hospital took an extended period of time to realise Mrs D was using it. She suffered from acute kidney failure, and died from a cardiac arrest.

The HDC commented that Mrs D’s progress notes were of a suboptimal standard as they were completed on an irregular basis, often with more than a week between entries, and entries were also too brief.

The HDC made adverse comment on the failure by rest home staff to document Mrs D’s progress and observations appropriately as that failure appears to have led to Mrs D’s GP’s inability to pick up on the subtle changes in her condition during regular GP visits.

This article was authored by Megan Neill, Solicitor, and Hugo Kan, Solicitor, in our Public Law team in the Wellington office.

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