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Aged care provider found in breach of Code for failure to manage pressure injury

In a report released today, Aged Care Commissioner Carolyn Cooper found Mayfair Lifecare (2008) Limited breached the Code of Health and Disability Services Consumers’ Rights (the Code) for their care of a man in his eighties. 

The man was in hospital level care at Mayfair following a recent stroke which had affected his mobility and ability to communicate. Despite care plans being in place to manage the man’s stroke symptoms, adequate care was not taken to manage his pressure injury.

Ms Cooper found Mayfair breached Right 4(1), which gives consumers the right to have services provided with reasonable care and skill.

Three shortcomings in care were identified in the breach. Several wound charts were in place but it was unclear which chart staff were following, which affected the coordination of wound care. The man did not regularly receive his prescribed pain relief prior to having his wound dressed (despite clear instructions in the Medi-Map medication system). Staff did not record on the man’s pressure care chart the times he was repositioned.

“I am critical that a vulnerable resident who could not verbalise when he was in pain was not given his morphine as prescribed. This meant he likely had to endure painful dressing changes,” Ms Cooper said.

“I am also critical that when the man’s daughter expressed concerns about her father’s pain and asked for him to be given pain relief, at times this was not given.”

Ms Cooper was also critical that the staff did not adhere to the medication management policy when recording when morphine was given, including the rationale for its administration and its effect.

“In my view, this raises concerns about staff adherence to policies and medication instructions, and communication with residents’ advocates,” she said.

Ms Cooper acknowledged the distress the event had caused the man’s family and offered her condolences to them for the loss of their loved one.

Ms Cooper made a number of recommendations to Mayfair, including that they provide a written apology to the man’s family for the issues identified in this report and that they conduct random audits of staff compliance for ten residents over three months to check adherence to the pain, wound and pressure injury management policies.

Mayfair accepted the report’s recommendations and said they had continued to review their processes to ensure learnings from this complaint are reflected in the standard of care delivered.

 

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