Considering risks for respite care admissions!
I read a case summary of an investigation after the discharge and subsequent death of a lady who had deteriorated during a three week respite care admission (Residential Aged Care Communiqué 2014).
Ms W was a 70 year old female living at home with her husband who was the primary care-giver. Past medical history included dementia, which was diagnosed about 15 years ago when Ms W was in her early 50’s. A few years later, Huntington’s disease was diagnosed. Prior to admission her husband attended the facility and discussed with the Manager his wife’s requirements. One week before admission Mrs W was reviewed by the GP who expressed no concerns about her health and provided a printed a list of Ms W’s prescribed medications from the digitally stored records, and a copy of the clinical charts.
On admission Mr W provided all documentation, medications, aids and appliances that provided comfort and were used constantly by Mrs W. Mr W was prepared to give a full care summary but was informed by staff this was not necessary. The next day, a nurse realised there was a discrepancy between the medication list generated from the digitally stored records and the list of medications on the care plan. Contact with the GP was initiated however Mrs W now experienced a UTI a risk Mr W had been very clear about and had identified the necessity of constant hydration.
About 10 days later, Ms W was restless and unsettled, struggling to take food and fluids orally and it was only at this time the medication discrepancy was revisited and a change in drugs was made to good effect. The remainder of her stay involved antibiotic treatments for the UTI, problems with swallowing, weight loss and deterioration in skin integrity. Nurses were regularly carrying out oral suctioning.
On return home Ms W had little oral intake and continued to have problems with keeping her airway clear. About five days after returning home, Ms W was seen by the GP and admitted to hospital. At the acute hospital pneumonia was diagnosed and treated with broad-spectrum antibiotics. After initially appearing to respond Ms W began to deteriorate and died about one week later.
Mr W was not satisfied by the residential aged care facility’s response to his concerns and notified the Coroner. The Coroner’s investigation considered a range of issues that included the admission and discharge procedures, medication management, delivery of care, documentation of care, accessing medical care when required by the resident and the facility response to Mr W’s concerns.
The coroner concluded Ms W was nearing the end of her life when she was admitted for respite care and that although the care received by Ms W “was inadequate …, the condition that led to her death was difficult to detect and she could have died from it at anytime, anywhere.” That said however, the Coroner found that the facility had inadequate admission procedures. The facility failed to fully acquaint themselves with Ms W’s special care needs and to ensure that all staff were aware of the care plan. The facility failed to adequately assess Ms W’s clinical needs and seek the necessary clinical specialists. They failed to ensure she received adequate hydration and nourishment, which increased her susceptibility to infection.
Pretty damning. The case provoked a very strong response with the Commonwealth Department of Social Services issuing an Industry Feedback Alert in October 2014 about identifying care needs in respite care. The Editor of this case study and the expert opinion were insistent that in spite of the short term nature of such an admission there was an obligation to achieve a care standard that equalled that provided by the husband.
“Unfortunately, residential respite care recipients are vulnerable to a number of administrative and care practices. In Australia, the average length of residential respite stay is short, only around three weeks, therefore there is a risk that in a Residential Aged Care Service admission and assessment processes may not be as rigorous as for someone coming in for a long stay or permanent admission” (Neville 2016).
Of course there are system pressures that create workforce issues that impact on the allocation of time to get to know a person from a clinical perspective let alone a personal perspective. We can all appreciate just how difficult short staffing, casual staffing, shifts and time pressures affect such situations. As individual nurses we often feel we are as vulnerable as these frail aged clients but none of us would want to find ourselves being investigated and found wanting. We can only do our best but I think one of the most important first steps would be to change our thinking.
Instead of approaching respite care as a babysitting exercise, one where our professional responsibility is limited by the duration of a short stay, we should approach each client in the most efficient and effective manner. We must make sure we undertake full admission procedures, that we have and maintain contacts with allied staff and family who can contribute to client needs and we communicate fully with our staff and the client so that the gaps highlighted in this Coronial investigation are not repeated.
There are some fabulous webinar recordings by Pam Savage regarding Nurses and the Law on the Nurses for Nurses Network. The Nurses for Nurses Network provides good information and CPD on an array of nursing topics in a range of easy learning ways including webinars and quizzes on the latest information that Nurses need to know – remember the Nurses for Nurses Network was created by Australian Nurses for Nurses! www.nursesfornurses.com.au