The family of an 85-year-old man complained to the Health and Disability Commissioner about the care he received while a resident in Ross Home and Hospital’s secure dementia unit for two months in 2010.
The man had dementia and was often agitated, aggressive and a high falls risk. However, Ross Home failed to ensure its staff regularly evaluated the man’s progress or responded appropriately to his falls and aggression.
Deputy Health and Disability Commissioner Theo Baker found that, on multiple occasions, staff used a lap-belt to restrain the man despite his wife’s objections to restraint and without complying with national Health and Disability Services standards and Ross Home’s restraint policy. In addition, Ross Home did not have appropriate documentation and incident reporting systems in place, and failed to ensure adequate communication between its staff. The Deputy Commissioner found that Ross Home was responsible for ensuring that the man received safe and appropriate care, and that these failures were indicative of systemic issues. Ross Home consequently breached the Code of Health and Disability Services Consumers’ Rights (the Code).
Ms Baker found the secure dementia unit’s Nurse Manager and Restraint Minimisation Co-ordinator also breached the Code because she failed to complete and evaluate the man’s support plan, or respond appropriately to his falls and aggression. She also failed to ensure that staff received appropriate training in restraint minimisation and failed to act appropriately in response to her staff restraining the man.
A second, experienced RN, was responsible for restraining the man on at least two occasions without following the Restraint Policy, and also breached the Code.
Ross Home has put in place a number of actions to address the issues identified in its service, including additional staff training in restraint minimisation.
http://www.hdc.org.nz/decisions–case-notes/commissioner’s-decisions/2013/10hdc01231
http://www.hdc.org.nz/decisions–case-notes/case-notes/restraint-procedure-at-a-secure-dementia-unit-(10hdc01231)
featured image – geripal.org
