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‘Care Home and registered nurse breach the Code for inadequate wound management’

In a report issued today, Aged Care Commissioner Carolyn Cooper found a care home and a registered nurse breached the Code of Health and Disability Services Consumers’ Rights (the Code) for their care of a female resident. 

The woman, who had a complex medical history, lived in rest home level care where she received wound management for her right foot in the weeks prior to her death.

Ms Cooper said deficiencies in the care provided to the woman by care home staff were systemic issues for which the care home was responsible. She found the care home breached Right 4 of the Code, which gives consumers the right to an appropriate standard of care | Tuatikanga.

“The care home’s systems were inadequate to support the woman’s timely care, intervention, and referral to more specialised care,” Ms Cooper said.

The breach covered several deficiencies in care. Weekly photographs of the woman’s wounds were not taken, despite this being a requirement of the Wound Care policy. Records were confusing and the referral system was unclear.

Ms Cooper considered that the registered nurse, as the person responsible for the overall care and direction of all resident and staff at the care home, also breached Right 4 of the Code.

The nurse did not manage the woman’s referral to the wound clinic satisfactorily and her record-keeping was deficient with respect to the woman’s wounds, leg pain and ongoing management. In addition, the nurse did not follow the care home’s Wound Care policy.

Ms Cooper also made an adverse comment about the care provided by two GPs. Although their actions did not amount to a breach of the Code, a breakdown in communication between the medical and nursing staff resulted in the woman’s referral being overlooked and treatment delayed.

Ms Cooper expressed her sincere condolences to the woman’s family for their loss.

Since these events, the care home has made several changes, including making improvements to GP communication and documentation and defining the process around referrals during GP rounds.

Ms Cooper recommended the care home, nurse and a GP provide written apologies to the woman’s family. She also recommended that the nurse reflect on her standard of record-keeping and that the GP review the level of detail in his clinical records. 


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