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Multiple staff at a Tauranga aged care centre provided sub-standard care to a woman with dementia, in the weeks before she died, the Aged Care Commissioner has found.
Commissioner Carolyn Cooper's report into the Elmswood Care Centre found it failed to intervene as the woman's health declined and the care she received for the time she lived at the centre until her death amounts to a breach of her rights.
Elmswood care centre is owned by Oceania Healthcare, and specialises in dementia care, for which the woman was admitted.
The woman suffered a forearm fracture and multiple unwitnessed falls, which were not properly documented, assessed, or followed up with care plans - and her family were not informed of the forearm fracture immediately, Cooper said.
The report found there were significant symptoms as the woman's condition deteriorated, but there wasn't timely or appropriate medical intervention.
The woman's condition worsened and she was taken to hospital, where she was diagnosed with septic shock and cellulitis.
She died 10 days later.
Wider issues at care centre
The breaches of the woman's rights are systemic issues for the Elmswood care centre, Cooper said.
"Elmswood had a responsibility to operate the dementia unit in a manner that provided its residents with services of an appropriate standard."
"The overall deficiencies in care provided in this case demonstrate a pattern of suboptimal care and a lack of critical thinking from staff members."
A registered nurse had also been found in breach of the woman's rights, for failing to carry out necessary observations or administer medication as required.
The nurse did not document or communicate effectively, and did not adequately monitor the woman's condition, or respond as she should have to her health decline.
Cooper acknowledged the family's distress and offered her condolences for their loss.
Several recommendations for the care centre were made in the report, including writing an apology to the woman's family and reviewing it's processes for resident admissions to dementia-level care.
Staff at the centre would also undertake training for their communication with older people and their family.
The report recommended the nurse write an apology, and noted she is no longer working as a registered nurse.
The Health and Disability Commission said Oceania Healthcare acknowledged the findings and were taking steps to address the issues identified.
In a statement Oceania said it had made significant changes.
“First and foremost, our condolences and sympathy are with the deceased resident’s family and loved ones. On behalf of the team, I’d like to reiterate our deep regret for the quality of care the resident received. We do not take this lightly.
"Following these events in 2020, Oceania has made significant improvements to our policies and processes for patient care at Elmswood Village. We have also carefully listened to, and are implementing, all of the HDC’s recommendations.
"The staff directly involved in this case, who are still employed with Oceania, have received additional training to ensure that all residents are provided with services of the highest possible standard.”
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