File image. Photo: Bret Kavanaugh / Unsplash
The Aged Care Commissioner has criticised a Tauranga care home after a dementia patient assaulted another resident as he lay unconscious and dying.
Both men lived in the specialist dementia unit at Radius Residential Care in Althorp in the early months of 2019.
In a report, Aged Care Commissioner Carolyn Cooper said Radius, Althorp failed to put in place effective measures to protect the man from the harm posed to him by the other patient.
Cooper said the home breached the Code of Health and Disability Services Consumers' Rights.
A complaint, made by the resident's daughter, brought to light a number of concerning elements of his care and protection, she said.
"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," Cooper said.
The incident was the last of a series of sometimes violent altercations as the patient repeatedly tried to enter the resident's room during a two month period that ended with the man's death.
The commission's report said staff had not identified a clear strategy to manage the escalating behaviours of the patient towards the man.
Days before the man died, family were present when the patient attempted to force his way into his room.
"I was pushing the bedside emergency button, on a lead beside Dad's bed. The [buzzer] 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," a family member said in the report.
Family members stayed overnight at the home for the next two nights out of concern for the man's safety.
The following morning the patient entered the man's room again and tried to wake him, shaking him from his bed. The man received a blow to the back of his head.
Multiple staff had to defend the man who did not regain consciousness and died later that afternoon.
An autopsy recorded the cause of death as pneumonia, with cardiovascular disease and pancreatic cancer being contributors.
At the time of the final incident there was one registered nurse and four healthcare assistants assigned to cover 58 dementia care
beds.
An internal report conducted by Radius conceded staffing levels in the dementia unit were inadequate.
Poor quality, unfinished and insufficient documentation was identified in the man's clinical notes for care plans, progress notes and charts.
The commission's report said key assessments were not carried out to identify that the man was entering an end of life stage which would have potentially seen him removed from dementia level care.
It also said communication with the man's family was not transparent in the days leading up to and immediately after his death.
Cooper recommended Radius Althorp apologise to the man's family and implement a number of changes identified in an internal review conducted by the home.
The report said staffing levels had been increased to ensure all patients received regular checks and additional training had been put in place on incident and accident reporting.