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Director of Proceedings v Norfolk Court Rest Home Ltd

Human Rights Review Tribunal HRRT No. 45/10 and 46/10 (12 May 2011)

In two decisions dated 12 May 2011 the Human Rights Review Tribunal (HRRT) made declarations that Norfolk Rest Home Limited (Norfolk Court) breached the Code of Health and Disability Services Consumers' Rights in relation to separate care of two different consumers.  Both matters proceeded by way of an agreed summary of facts. The declarations were made by consent, the parties having resolved the issues of damages and all other matters (including in respect of costs) as between themselves.

At the relevant time Norfolk Court had employed a registered nurse who was a recent graduate and lacked any gerontology nursing experience. When first employed the nurse was to be the sole registered nurse at Norfolk Court and was not suitably skilled or trained to be the sole person responsible for the provision of nursing services to residents. Norfolk Court failed to provide the nurse with sufficient mentoring, training and education to properly undertake her role. Norfolk Court accepted vicarious liability for the breaches of the Code by the registered nurse.

Norfolk Court did not have adequate policies and procedures in place for:

• Resident assessment on admission;
• Falls prevention;
• Falls risk assessments;
• Care planning;
• Incident and accident reporting;
• Doctors visits;
• Communication/consultation with families; and
• Continence management.

Norfolk Court did not ensure that its staff were adequately trained and familiar with the policies and procedures that were in place.  It did not take reasonable steps to ensure that staff complied with these policies and procedures.

Consumer A (HRRT No. 45/10)

Mrs A was admitted to Norfolk Court on 4 January 2007 as her daughter was unable to care for her. She was 81 at the time.

In the two years that Mrs A was resident at Norfolk Court, there were no recorded family meetings as part of the care planning process. Care plans that were made failed to include assessments for falls, pain or pressure risk. Mrs A suffered four falls between December 2008 and February 2009. She was later found to have a fractured ankle and a fractured hip. After each of these falls a new 'falls risk assessment' should have been undertaken; however, no falls risk assessment was undertaken at any point. Despite being assessed by the registered nurse, no injuries were identified until 6 weeks after the hip fracture and 1 week after the ankle fracture when an x-ray was taken. Before this time Mrs A was encouraged to mobilise and walk with her injuries despite complaining of ongoing pain and expressing reluctance to comply. Mrs A was in significant pain without adequate treatment for a period of four months as the registered nurse failed to adequately assess her pain and address it. Norfolk Court's pain management policy was inadequate.

Consumer C (HRRT No. 46/10)

On 16 December 2008 C was admitted to Norfolk Court specialist dementia unit as his family were no longer able to manage his increasingly violent behaviour, wandering and mood changes. 

Throughout C's one month stay at Norfolk Court the registered nurse made only two entries in C's progress notes.

There was no plan to manage C's behaviours (including nocturnal wandering) to promote his safety prior to considering the use of medication.  No analysis of C's increased incontinence was undertaken.

Norfolk Court did not have in place polices and procedures for medical reviews and doctor visits.  C was  put on a medication trial and was reported to be stumbling around the floor, falling at times. C was given further medication and shortly afterwards was found attempting to jump off a balcony.

On one occasion a physical restraint (an enabler) was used to prevent C from falling off a chair.  There was no assessment of the risks involved in the use of this restraint nor documented monitoring of it.

C sustained injuries as a result of four falls during January 2009. He was not seen by the rest home doctor until after the third fall.

Overall, C received insufficient professional nursing assessments. He rapidly deteriorated and suffered two subdural haematomas and herniation of the brain. C died in January 2009.

The Tribunal's decisions are available at http://www.nzlii.org/nz/cases/NZHRRT/2011/.