The death of a woman who died within a day of moving into a rest home was linked to nursing staff failing to follow correct procedures.

A report released today by the Deputy Health and Disability Commissioner said the care provided to the woman fell short of acceptable standards in a number of areas, in a time frame of less than 24 hours.

The woman, aged in her 70s, had suffered from dementia and type 2 diabetes. She had been cared for by family at home until an assessment indicated that she needed hospital-level care.

She was admitted to a rest home owned and operated by Oceania Care Company Ltd in 2018.

What followed was a series of failures and the woman died less than 24 hours after her arrival.

Oceania general manager of nursing and clinical strategy acknowledged in a letter to the Health and Disability Commissioner [HDC] that there were deficits in the woman's care and apologised to her daughter for the inadequate quality of care provided to her mother.

The daughter commended Oceania for taking responsibility but said that without answers and assurances that the same events would not happen to another family, she was unable to accept Oceania's "second-hand" apology.

The woman's daughter handed over her mother's medications on admission to the rest home, including her insulin and warfarin.

At that time, the only source of medical history was from the daughter, named in the decision as Mrs B.

A profile had been created on the rest home's Medi-Map database, and a fax was sent to the rest home's doctor and the woman's usual GP, telling them the woman had been admitted.

There was also a request that the GP supply a list of the woman's medical conditions, and to add her medication to her Medi-Map profile.

But the medical centre and the doctor said the fax was never received.

Staff at a rest home where a woman died within 24 hours of being admitted were "unsure of medication or medical history". Photo / 123RF

The Deputy Commissioner said because it was a planned admission, there was opportunity for planning of the woman's care.

Progress notes for the woman's care soon after she was admitted showed there was no available medical history except the woman was on warfarin and insulin, that she had a pressure injury not seen on admission, cellulitis in her left leg and a fungal infection on her right foot, "for the GP to sort".

There were no further notes made regarding cellulitis, and other than recording that the woman was on insulin, the nurse did not document any further details as required by the Insulin Administration Policy and Protocol.

The warfarin administration policy required that on admission, the admitting nurse must ensure that relevant information was obtained, including a prescription for the warfarin, the last time it was given, and the current dose.

The report found that Oceania did not have any specific policy on when to escalate issues to a GP or nurse practitioner; however, the warfarin policy did state that faxes regarding prescriptions were to be followed up by phone calls.

Mrs B stayed at the rest home with her mother until about 4pm and returned at 7.30pm to find her walking around asking other residents where her daughter was, as she needed her insulin.

A blood-sugar level reading showed it was high, and in need of urgent attention. Mrs B asked the duty nurse to administer the appropriate medication and was told she couldn't.

Mrs B did not understand at the time that this was because the doctor had yet to prescribe the medication.

However, the nurse gave Mrs B the bag of medications so she could administer short-acting insulin herself.

Mrs B left a note for the nurse to make sure her mother would also be given long-acting insulin.

She assumed that observations and a further blood sugar check would be completed by the nurse who saw the note.

No blood sugar readings were taken by staff on the day the woman was admitted.

Just after 6am the next day the woman was reported as lying asleep in her bed, but half an hour later she was found lying across her bed unresponsive.

She was rushed to hospital by ambulance, but died just before 8am.

The public hospital's records state that staff were "unsure of medication or medical history".

The commissioner could not overemphasise the significance of what had transpired, and the dire consequences for the woman, and her family.

"Registered nurses across many practice settings are key providers of diabetes clinical care.

"Older people receiving hospital-level care in an aged residential care setting are no exception, often presenting with multiple comorbidities and complex health conditions, including type two diabetes."

The report said the case highlighted the importance of accurate planning for new admissions, and of vigilance when dealing with consumers who needed their medications in a timely manner.

It also emphasised the importance of critical thinking and the use of initiative by registered nurses when responding to different scenarios, and the vital role of communication with both colleagues and consumers and their whānau.

Overall, the HDC found the care provided to the woman fell short of acceptable standards in a number of areas in a time frame of less than 24 hours.

At least three of the four nurses involved in her care failed to fulfill their clinical responsibilities and adhere to policies and procedures.

"Policies are of little use if they are not followed by staff," the report said.

Oceania has implemented changes at the rest home.

- Tracy Neal, Open Justice