The man was not supposed to be left alone in the bathroom but he was and he fell on four occasions. File pic Photo: 123RF
The Health and Disability Commission has found a Bay of Plenty woman was not told her husband had several falls in hospital, one of which contributed to his death.
The man was admitted to a Bay of Plenty public hospital in 2019, where he was assessed as having a high fall risk.
His care plan identified he should not be left alone in the bathroom, however, on four occasions, staff left him unattended and he fell.
His wife was notified of only one fall.
After the fourth, the man complained of neck pain and it was found he had fractured a vertebra in his neck.
He died from life-threatening complications a short time later.
Deputy Commissioner Deborah James said there were several issues with the care the man received.
"[There was a] lack of critical thinking applied to the patient's falls risk assessment in relation to his bathroom needs," she said.
There was also a consistent failure to adhere to his care plan and the falls policy was not followed by several nurses and doctors.
"In three cases, the patient's wife was not informed of her husband's falls and after one fall an incident report was not completed.
"These inactions or failures by multiple staff members, and their failure to adhere to policies and procedures, demonstrate a pattern of poor care and a culture of non-compliance with policies," James said.
She recommended Te Whatu Ora Hauora a Toi Bay of Plenty make a written apology to the widow, provide falls training to all house officers and nurses and consider providing fall prevention mats for at risk patients.
James said it should also implement ongoing training for all nurses and healthcare assistants on assessment and fall risk monitoring.
"Six months after this training, [Te Whatu Ora should] conduct an audit to assess whether the training has reduced the number of falls," she said.
Te Whatu Ora Hauora a Toi Bay of Plenty said since the complaint it had already made a number of changes.
This included developing an online module and onsite "care companion teaching package" for all staff on falls.
It had also made its call bell system audible for all staff and improved its fall mitigation, reporting and investigation processes.