Resthome failed in care of patient

REVIEWED: The Health and Disability Commission's deputy commissioner Rose Wall has found Kandahar Home failed to assess and manage a dying woman's pain adequately. PHOTO/LYNDA FERINGA

In the days leading up to the death of a terminally ill Masterton woman, she was denied pain relief by a resthome nurse, who had decided she wasn't in enough pain to need it.

The resthome also failed to administer prescribed antibiotics to the woman on two occasions and once mistakenly gave her double the dose of paracetamol, the Health and Disability deputy commissioner Rose Wall has determined.

In a decision released earlier this week the commissioner found Kandahar Home, owned by Presbyterian Support Services, and nurses involved with the woman's care failed in her care, especially managing her pain and assessing her pain levels in the last days of her life.

A nurse involved in the woman's care failed to deal appropriately with her family and the home failed to properly train staff, Ms Wall's findings state.

The nurse at the centre of most of the complaints by the woman's family, says she was used as a "scapegoat" by the resthome.

Names of everyone involved including the nurse have been withheld.

The woman was admitted to Kandahar for palliative care in 2012, the same year the rest home started providing palliative care to terminally ill patients. She died several months later from lung cancer.

Prior to her death, the woman lost the ability to communicate.

Her daughter said in a complaint to the Health and Disability Commission that staff from Kandahar made her mother feel like a "drug seeker" and that she often had to wait for a staff change to receive an increased dose of morphine prescribed by her doctor. Her daughter had been concerned the ill woman suffered unnecessary pain in the days leading up to her death with one particular nurse refusing to administer morphine when the family asked, even though the doctor charted it.

The deputy commissioner also found Kandahar failed to retain sufficient records and didn't keep clear and adequate records of medication administration.

Ms Wall has recommended the Nursing Council of New Zealand conducts a review of one of the nurses in question.

She has also recommended the home reviews its policies and procedures regarding palliative care, amend its medication manual to reflect end-of-life medication administration issues and develop a new end-of-life care policy.

The resthome is also been ordered to audit training of all staff providing palliative care and that all nurses receive palliative care training and must provide the commissioner with an updated training programme cycle for nursing staff.

It has three months to complete the recommendations.