'Left in her chair covered in faeces' - widespread failures at resthome

There were widespread failures at a Geraldine resthome which did not properly care for three women, the Health and Disability Commissioner (HDC) has found.

The HDC report followed three separate complaints about the standard of care the women received from McKenzie Healthcare Limited between 2020 and 2022.

The resthome said it had worked to address the issues and improve quality and consistency.

Known in the report as Mrs A, Mrs E and Mrs F, the report found the resthome left one of them covered in faeces and another in a soiled bed in Covid isolation. She later died while still in isolation.

• Mrs A complained about her lack of personal space for bathing, her lack of care and the dismissive attitude of staff and management at the facility, and her social isolation.
• The daughter of Mrs E said that when she was isolated during a Covid-19 outbreak, there was a lack of support with hydration, nourishment, and hygiene.
• The daughter of Mrs F raised issues with a lack of support for toileting and a poor call-bell response time.

The commissioner found McKenzie Healthcare in breach of Rights and the Code of Health and Disability Services Consumers' Rights for all three women.

No 'reasonable standard of care'

The HDC found that between 2021 and 2022 there was a significant turnover of multiple staff at a frontline and management level, including five general managers.

The current general manager stepped into the role despite having no previous knowledge of New Zealand's aged-care systems, and did not receive a formal orientation for the job.

Aged Care Commissioner Carolyn Cooper said after carefully reviewing all the information she considered that "McKenzie Healthcare did not provide a reasonable standard of care for the three consumers".

"I consider that the care provided in each case demonstrated a system-level failure. There was a consistent pattern of poor care for multiple consumers, and inadequate organisational systems to support staff in providing effective care.

"In my opinion, this resulted from a lack of robust leadership, a lack of strategic direction, and poor clinical oversight. This had a cascading effect on healthcare delivery and resulted in a failure to provide appropriate care and assistance to McKenzie Healthcare staff and residents," said Cooper.

Current clinical general manager Jo Fenton told RNZ in a statement the report had been taken on board.

"We acknowledge and accept the findings of the Health and Disability Commissioner's report. Since then, we have been working diligently to address the issues raised and to improve the quality and consistency of our service delivery," she said.

'Left in her chair or bed covered in faeces'

Mrs A was a 67-year-old woman with multiple comorbidities, including type two diabetes which required insulin, a stomach hernia, and a previous stroke. She was legally blind and had two stomas, and was also prone to recurrent urinary tract infections.

Although a long-term care plan (LTCP) identified that Mrs A needed full assistance with hygiene and toileting, with her stoma bags to be checked and changed at least twice a week - she had several "blow outs" and was "left in her chair or bed covered in faeces". This led to her stoma becoming infected, and she was banned from using the shared toileting facilities - leaving her in "total isolation".

The report also stated that Mrs A was left in her soiled clothes for extended periods, and the lack of help from staff led her to discharge herself from McKenzie Healthcare.

The investigation found no evidence of a short-term care plan when Mrs A suffered gastroenteritis and was put in isolation, and no formal training for staff around infection control.

It stated that "she was unable to be showered even after being soiled with faeces due to blow-out of the colostomy bag. She was made to wait until staff were available to shower her and clean up afterwards. This furthered her feelings of social isolation and emotional distress," the report said.

'Curled up in a soiled bed with matted hair'

The daughter of Mrs E complained about her care during a Covid-19 outbreak in 2022, and says she passed away after a long period of isolation when she received little attention and assistance.

The 98-year-old was admitted to McKenzie Healthcare in 2020 for hospital-level care, and had a history of glaucoma, dementia with marked short-term memory loss, visual impairment, frailty, gluten intolerance, malignant melanoma, osteoarthritis, and hearing impairment.

When she tested positive for Covid-19 in 2022, Mrs E was placed in isolation for 16 days and was still isolated when she died. The investigation found no reason for her extended isolation.

"No rationale for this extended isolation was documented, and there is no evidence that an assessment was completed at the 7- or 10-day point to assess whether continuing isolation was necessary," said the commissioner.

The resthome told the HDC that other than a low grade fever, Mrs E did not have any other Covid-19 symptoms. When her granddaughters visited her, they found Mrs E "lying curled up in a soiled bed with matted hair, and dry and scaly skin, and it appeared that she had not been moved for some time".

The family said her dentures had not been fitted so she could not eat, there was no straw for her to drink fluids with, and she had been complaining of hunger.

"When Mrs E's family challenged staff about their lack of attention to Mrs E, staff responded that it was difficult to continually don their PPE and therefore, frequent visits and checks had been avoided," the report stated.

McKenzie Healthcare reviewed their care of Mrs E, and found trends of poor communication and documentation, no records of staff training on fluid and food recordings, no activities for Mrs E in isolation, no liaison with GPs and no end of life management was implemented.

'Poor staffing and a bad work culture'

The third complaint was made by the daughter of Mrs F, who was concerned that staff at the resthome took too long to answer the call bell because of "poor staffing and a bad work culture".

Mrs F was a 79-year-old woman who was transferred from McKenzie Village to McKenzie Healthcare for hospital-level care because of a decline in her health and ability to manage the activities of daily living. She had poor mobility and required full assistance with all personal care - including toileting and incontinence as she needed to urinate four to five times overnight. She also had chronic kidney disease, congestive heart failure and lethargy.

Staff told HDC that Mrs F had a fluctuating mood, and she became tearful and screamed when left alone for more than 10 minutes. They said she became verbally aggressive towards healthcare assistants, and frequently complained about elder abuse. This made them anxious about attending Mrs F alone, which potentially delayed their response to the call-bell.

Mrs F's daughter told the HDC that it took one to 1.5 hours for the call-bell to be answered, leading to "her dignity being taken away". The call-bell system is run remotely by a third party, and rest home residents are given a pager for the caregiver assigned to that room. After a family meeting about the delay, a registered nurse pager was given to Mrs F to use when call-bells were not answered.

"No minutes were provided for this meeting, and there is no evidence of the corrective action plans or investigations undertaken into the complaint," the report said.

McKenzie Healthcare acknowledged that extended call-bell response times may have been due to staff attending to other residents. It apologised for this and stated that there was no excuse for not checking on Mrs F.

The investigation also found problems with the care of Mrs F's incontinence. "It appears from the documentation that information was recorded inconsistently on the forms. Some days recorded only one episode of urine being passed, while on other days there were no entries," the report said.

Recommendations

The commissioner recognised the resthome had made significant changes since 2022, and made a number of recommendations to McKenzie Healthcare.

The recommendations include:

• A written apology to the women and their families
• Complete education on communication with and about older people and their whānau, including strategies for ensuring that changes in resident needs are documented safely and communicated appropriately to minimise the risk of similar occurrences in the future
• Complete education on caring for people living with dementia mate wareware, including around person-first care, recognition of change or decline, use of the STOP and WATCH tool, and related responsibilities in care and communication
• An update on the changes made to improve its systems and processes, within an evaluated corrective action plan
• Discuss with the nursing team the importance of accurately recording all concerns raised by the family in the resident's clinical record
• - Provide copies of certification of completion in relation to HDC's online modules for all current staff, within six months of the date of this report.
• - Complete an audit of all call-bell response times and provide a copy of the new policy
• - Provide evidence of the standards of care it has developed for its caregivers and evidence of the training provided to caregivers, within 12 months of the date of this report.
• Consider seeking support from South Canterbury ARC health experts to strengthen its clinical practice standards, to inform individualised assessment, planning, and delivery of safe resident care

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