August 4, 2019

Carino Care Russel Lea nursing home neglect

Location:
Carino Care Russel Lea nursing home
Date of Meeting:
13/12/2018
Time of Meeting:
TBA
Attendees:
Luigi’s Family
Chairperson:
Janice Stokes



Agenda Items


        1.         
Apologies:
        2.         
Attendance:
        3.         
 Agenda Items:
·         Welcome and introductions 
·         Medical Review/outcome.
o   Unable to sleep - Left my blind father with an abusive patient and said i needed to get a doctor to check on his sleeping patterns when they moved other residents from this room in the past and were aware of this mans erratic behaviour.
o   Psychogeriatrician 
o   Wheezing - left my father sitting in urine all night, this night i called the ambulance to the nursing home my father caught bronchitis.
o   Hospital transfer/ambulance - they lost my fathers discharge papers but continued to give him medication without looking at the discharge letter from hospital and doubled up on his insulin.
·         Single room/RADS - they prefer to make money on sharing rooms then the resident
·         TV/Italian channels/radio/headphones - they never followed up on emails and never turned on the radio for my father in his room.
·         Case conference - the head RN Nurse Rhia was at this meeting and refused to bring my father a blanket when he was cold, she ignored him and stepped on his toes to lift him up.
·         Feedback forms/raise issues with RN and none of the nurses follow up on complaints they actually deny it.
·         After Hours visiting  - the RN Nurse Evangeline locked me out when i was my fathers carer said my father was asleep when i could hear him screaming down the hall.  She then lied to the Manager about me to try to stop me from visiting my father.    
·         Physio assessment/Walking frame. they gave no excersise to my father until i complained to them left him in a chair to eat pee and poo
·         Money left with Luigi - money was stolen from my fathers pocket.
·         Lifestyle/interests/emotional support - they failed my father.
·         Personal care/clothing   /wrapping himself in a sheet / assistance. My father wrapped himself in a sheet because he was freezing cold.
·         Diabetes Management/ BSLs/water bottles - no water, no one attends to my father when he calls them they just close the door at night and refuse to attend to him , my father smacking the table with hands to get assisitants no buzzer was provided till the last month of his life.
·         Night staff /security cameras - night staff are bullies and abusive.
·         Comfort chair   - they threw my fathers chair over the fence and pretended no body new where his recliner was
·             Carino Care do not report falls and left my father in a chair for 2 weeks without excersise.
·         Staff interviews.     The staff are not qualified, lack empathy and kindness. I placed a video camera inside this facility the CEO James Grealy banned me from visiting my father and called the police to try have me arrested.
        My father past away on the 27th of Febuary 2019. 

                     




7.
Next meeting date:    TBA



Premature Death - Carino Care Russell Lea

Case ID: S19/013886
Ms Eva Rinaldi
By email: bodyartist@bigpond.com
Dear Ms Rinaldi
As you know, we have been conducting a new complaint resolution process in
relation to your concern about the care and services that were provided to a resident
named Stella at Carino Care at Russell Lea (the service).
This follows your request for a review of our decision in your original complaint.
Since that time we have worked with you, the service and Stella’s representative to
address the issues.
Having carefully considered the concerns you raised, including your feedback on the
limited information we could provide you about our findings, I have decided to end
the resolution process on the basis that Carino Care has addressed the issue to the
satisfaction of the Commissioner. My decision means I will take no further action in
relation to this issue. I have attached feedback about the process and the outcome
with this letter (Attachment A). As you are aware, after taking into account Stella’s
representative’s wishes and our own guidelines I am only able to provide you limited
feedback.
Please be assured that we have objectively looked at all of the relevant information
available to us. We have considered documentary evidence and information from
multiple sources, including you and the service. We have also taken into account
expert advice from our clinical advisors. We found serious concerns in relation to
care and services. The service acknowledged these and has since provided
evidence of a range of actions taken to resolve these concerns. Your complaint has
made a difference and has resulted in a positive outcome for other people receiving
care. While I understand you are seeking a harsher penalty be applied to the service,
I am satisfied that the issue under consideration has been resolved to our
satisfaction.
2
I can let you know that during the new process, we also shared information about our
findings with the Commission’s Quality Assessment and Monitoring Group. While you
will not be provided feedback on its actions, our referral means that in our
colleagues’ ongoing accreditation work, the findings of your complaint can be
considered and they are able to monitor the actions the service has implemented
for their effectiveness.
I would also like to acknowledge that the findings of the new process are in contrast
to the findings of your original complaint. Our review process is in place to improve
the quality, efficiency and effectiveness of our decision-making and to enable people
to question the merits of decisions that have been made. In these circumstances,
where the review process has identified quality improvement opportunities, we
provide feedback about our findings to the staff originally involved in the decision
along with the broader complaints teams where relevant. This allows staff to learn
and improve for future complaint handling. Please be assured I will provide feedback
to the complaints team.
If you have any queries or concerns about my decision or our process, please do not
hesitate to contact Mr Scott Walker, Review Manager on 1800 500 294. You are also
able to contact the Commonwealth Ombudsman if you have concerns about our
actions, on 1300 362 072.
Thank you for your assistance and cooperation during the new resolution process.
Yours sincerely
Emily Grayson
Delegate of the Commissioner
Aged Quality and Safety Commission
12 June 2019
1
Attachment A
Aged Care Quality and Safety Commission
Notification to confidential complainant on the New Resolution Process
Summary of the issue, new process and findings
On 14 January 2019 we received your complaint about the care and services
provided to a resident named Stella at Carino Care at Russell Lea (the service).
You expressed concern that Stella fell and hit her head in the bathroom on
20 December 2018. You told us that Stella lived at the service with her husband
Frank.
After examining the issue and speaking to Stella’s nominated representative,
a decision was made to finalise the complaint on the basis that an aged care
consumer identified in the complaint did not wish the issue to be considered by the
Commissioner.
On 18 February 2019 you requested a review of the decision because you were of
the view that too much weight was given to the representative’s view and as such
the issue in the case was not resolved. You said there are aspects of the fall which
warrant our consideration and there was an ongoing risk to current residents.
Following detailed review, a new delegate decided to undertake a new resolution
process in order to further investigate the issue and obtain additional information
from the service.
During the new resolution process, we have considered information from the original
case including your views, new information from the service, Stella’s representative’s
views and advice from our expert clinical advisors. We visited Stella’s husband at the
service to consider his views.
In summary, we found concerns with the service’s immediate management of
Stella’s condition after she fell, the care provided after her return from hospital, its
documentation procedures, behaviour management and its falls management policy.
The service acknowledged these deficiencies and has taken actions to address the
concerns. I have seen evidence of the actions and I am satisfied that these actions
address the deficiencies. On this basis and having considered all of the available
information I am satisfied the issue has been reasonably addressed.
Given the nature of the issue and the systemic actions which have been undertaken,
during this process we have referred information about this complaint and our
findings to the Commission’s Quality Assessment and Monitoring Group for its
consideration and monitoring when undertaking its accreditation work.
Greater detail about the new resolution process, my findings and decision, is below.
2
New resolution outcome
Issue Concern that Stella fell and hit her head in the bathroom on 20
December 2018.
During the original case you told us that Stella had fallen and hit her head in the
bathroom on 20 December 2018. You were concerned that staff were not readily
available to toilet Stella, so her husband who also required care was forced to toilet
her despite the risk this posed.
The service provided information and documentation relating to Stella’s incident and
the care that was provided to her afterwards.
Stella’s nominated representative was contacted to seek his view on the issue
raised. He told us that he was aware of the fall but did not share your concerns and
he was satisfied with the overall care provided. He did not want the matter to be
further considered.
The original decision took into account their view and a decision was made to finalise
the complaint on the basis that an aged care consumer identified in the complaint did
not wish the issue to be considered by the Commissioner.
In seeking this new process, you said that:
 The issue was not satisfactorily resolved because there were aspects of the fall
which warranted our consideration and there was an ongoing risk to current
residents.
 Staff were not available to assist Stella as they should have been.
 Stella was at risk of falling but staff allowed her husband to take her to the toilet
despite his own health which included using a walking frame.
 Stella and other residents were left alone in the lounge room for long periods of
time every day so there was an ongoing risk to those residents.
To further inform our investigation we obtained additional documentation from the
service relating to both Stella and her husband’s care. These included relevant
clinical assessments and service policies.
After reviewing the information available and considering advice from our clinical
advisors we found that:
The immediate management of Stella’s condition after she fell
 We found concerns with some aspects relating to this concern. While I am unable
to share the full details with you as they include Stella’s personal information I am
able to inform you of the actions the service has undertaken to reduce the risk of
this recurring. The service has:
o provided all registered nurses at the service with mandatory falls management
and documentation training
o reminded all registered nurses to follow the instructions within the falls and
unwitnessed fall/head trauma incident flow charts in the event of a resident
experiencing a fall
3
o taken other action which we consider appropriate.
Stella’s care after she returned from hospital
 We found issues with some aspects relating to this concern. While I am unable to
share the full details with you as they include Stella’s personal information I am
able to inform you of the actions the service has undertaken to reduce the risk of
this recurring. The service has:
o provided all registered nurses at the service with mandatory falls
management, incident follow up and documentation training
o updated the registered nurse duty list with clear instructions on follow up for
residents returning from hospital
o arranged for management and registered nurses to follow up all incidents
daily to ensure correct strategies for falls management and prevention are
addressed
o reminded staff to archive previous assessments, including care plans, prior to
entering details of new assessments
o requested the physiotherapist supervisor to provide post falls and return from
hospital training to the service physiotherapist.
The service’s falls management policy
 We considered the post falls provisions within the policy did not align with
contemporary falls management guidelines. This represented a departure from
expected levels of care because they did not:
o provide details of the circumstances warranting the taking of neurological
observations
o refer to a neurological observations procedure, which outlined the frequency
and duration that neurological observations were to be taken and maintained
o differentiate between the actions staff were to take in the event of witnessed
or unwitnessed falls
o direct staff to provide basic first aid to minor injuries following falls
o provide details of the circumstances warranting immediate transfer to hospital.
 We asked the service to consider taking appropriate action to address the
identified deficits within the policy to reduce the risk of this level of departure from
expected levels of care recurring. In response the service:
o revised its falls management policy to include:
 details of the circumstances that warrant the taking of neurological
observations, together with instructions regarding the frequency and
duration that neurological observations are to be maintained;
 details of the actions staff are to take in the event of witnessed and
unwitnessed falls, such as administering basic first aid; and
 details of the circumstances warranting immediate transfer to hospital
o provided mandatory falls management training to all registered nurses at the
service
o sent reminders to all staff regarding the revised falls management policy and
the need for them to acquaint themselves with the provisions within the
revised policy
o placed a reference guide regarding neurological observations at the nurse’s
station.
4
Documentation procedures
 We considered some of the documentation practices within the service are not
consistent with contemporary practice and this represented a departure from
expected levels of care.
 We asked the service to consider taking appropriate action to address the
identified deficits in documentation to reduce the risk of this level of departure
from expected levels of care recurring. In response the service:
o provided documentation training to all registered nurses at the service
o reminded registered nurses of their legal obligation to document details of the
care they provide
o provided an education session to staff which included advice on how to
archive documents within the computer system
o is undertaking ongoing, monthly documentation training with nurses.
Management of Stella’s husband’s behaviour
 We found issues with some aspects relating to this concern. While I am unable to
share the full details or the actions with you as they include Stella’s husband’s
personal information, I am satisfied the action taken has addressed this concern
and has reduced the risk of it recurring.
After reviewing the evidence of the above actions being undertaken, I consider the
service has taken appropriate action to address the previous identified deficits in
care. Nonetheless, we undertook additional actions to further satisfy ourselves the
issue in this new process had been addressed and the risk to other residents was
being managed appropriately.
On 12 April 2019 we visited the service and spoke to Stella’s husband and other
residents. While I am unable to share his views with you I can assure you that we
have considered his information.
In summary, we found concerns with the service’s immediate management of
Stella’s condition after she fell, the care provided after her return from hospital, its
documentation procedures, behaviour management and its falls management policy.
The service acknowledged these deficiencies and has taken actions to address the
concerns. I have seen evidence of the actions and I am satisfied that these actions
address the deficiencies. On this basis and having considered all of the available
information I am satisfied the issue has been reasonably addressed.
As noted above, given the nature of the issue and the systemic actions which have
been undertaken, during this process we have referred information about this
complaint and our findings to the Commission’s Quality Assessment and Monitoring
Group for its consideration and monitoring when undertaking its accreditation work.
Your feedback
When providing your feedback, you said that you are satisfied with our findings,
however you are not satisfied that the service has not been penalised by sanctions.
END OF DOCUMENT

“It’s A Relief” Errors Out In The Open By Caroline Egan - HelloCare Editor. Aug 2, 2019


iStock-471704753

“It’s A Relief” Errors Out In The Open


Aged care operators who don’t care properly for residents should face “heavy penalties”, says a family who saw their loved one endure a horrifying ordeal at the nursing home where he spent part of the final months of his life.
Eva Rinaldi, whose father Luigi Cantali was neglected at the aged care facility Carino Care Russell Lea, told HelloCare she was glad the facility’s problems are now out in the open.
“I’m glad someone’s bringing it to light now,” she said. “It’s a relief.”
“The nursing home made me feel like I was the bad one becuase I was asking about my dad,” she said.
Safety, Health, Wellbeing “At Serious Risk”
In May 2019, Carino Care Russell Lea failed to comply with 24 of the 44 quality standards, and was placed on a timetable for improvement.
Some of the failings identified in the audit report include: turnover in the management team, insufficient monitoring of staff, a “significant increase” in medication incidents, care recipients experiencing pain and distress from poor skin care, no system for managing incontinence, lack of skills to manage care recipients with “challenging behaviours”, and crowded communal areas.
The report also states staff lacked the skills to properly support palliative care. “Care recipients have died in pain and distress due to constipation, unmanaged pain and anxiety,” it tragically states.
Janet Anderson PSM, Aged Care Quality and Safety Commissioner, told HelloCare, “A decision was made that the failure to comply with seven expected outcomes of the Accreditation Standards has placed the safety, health or wellbeing of a consumer at serious risk.”  
The Department of Health may take further regulatory action, she said.  
The commission will continue to monitor the performance of the facility, and Carino Care Russell Lea will receive an unannounced audit before its period of accreditation expires at the end of November 2019, Ms Anderson said.
Carino Care Russell Lea issued a statement to HelloCare stating, “Carino Care has learnt from the audit and is working closely in a regulatory process with the Department of Health and Aged Care Quality and Safety Commission to remedy the non-compliance.”
The facility has engaged a nurse advisor and clinical consultant to help it meet the requirements of the timeframe for improvement.
“Carino Care takes its responsibilities as an approved provider of aged care seriously and is committed to and will improve the culture and care and service outcomes for the consumers who reside within the home,” the statement said.
Care Became Worse When Family Complained
Ms Rinaldi said that when her father, who was blind and living with dementia, was at Carino Care, she tried talking to management about her concerns he was not being properly cared for.
But her requests were ignored. The situation deteriorated further when management became aware Ms Rinaldi had placed a secret camera in her father’s room.
Management subsequently banned Ms Rinaldi from visiting her father for two weeks. “That’s when it (the care her father received) got even worse,” she said.
The family eventually made the difficult decision to move Mr Cantali to another facility, but sadly he died only days after moving.
“It was very difficult to make the decision (to move him) because I know it be be detrimental (to their health) to make changes,” Ms Rinaldi said.
Mr Cantali’s Story “Front And Centre” Of My Mind: Minister
The Aged Care Minister, Richard Colbeck, told HelloCare that since taking on the aged care portfolio, stories such as that of Mr Cantali are “front and centre” of his mind.
“Mr Cantali deserved better care, what happened to him was completely unacceptable.
“I am advised Carino Care is working closely with the Department of Health and Aged Care Quality and Safety Commission to remedy this non-compliance.”
“The service has made weekly contact with the Department of Health to report on improvements being made. They have self-instigated the same actions they would be required to undertake if a formal sanction was put in place.”
“I am advised that Carino Care is implementing improvements including additional staffing; new policies and procedures; investment in resident amenities, and are working closely with the Aged Care Quality and Safety Commission. 
“Our whole focus is on improving the delivery of Aged Care for Senior Australians.”
Cameras Should Be In All Nursing Homes
Ms Rinaldi told HelloCare she was disappointed the facility didn’t receive heavier penalties, even after the regulator identified such serious concerns. The facility’s failings had also been highlighted in a report by the ABC titled ‘This is what neglect looks like’.
“Something needs to be done. Something is seriously wrong,” Ms Rinaldi said.
Ms Rinald also recommends cameras be installed in all nursing homes, and that it be made easier to track the history of an aged care facility when it changes name.
Carino Care Russell Lea was formerly known as Ark Health Care Russell Lea and had failed a quality audit in May 2018.
“Even when the name changed, the staff remained the same,” Ms Rinaldi said, explaining she would never have sent her father to the facility had she known its history.
If anyone has a concern about an aged care service, they should contact the Commission on 1800 951 822.
HelloCare also contacted the Department of Health for a comment but at the time of writing had not yet received a response.
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Contributor
Caroline Egan - HelloCare Editor
Caroline Egan has been a writer and editor for more than 20 years. She has worked across several sectors, including banking, finance, economics, real estate, and aged care. She was Managing Editor at Macquarie Bank for several years, and also spent a number of years presenting financial market news on television and radio for CommSec. Caroline loves playing Scrabble, going to the movies with her funny children, and walking in nature.


August 3, 2019

Aged Care and Quality Safety Commission Letter that decided that they will not take any further action in relation to this compalint.


If the Aged Care Quality and Safety Commission people acted sooner and did something maybe my father would not have suffered and maybe he would be still alive.

Aged Care Complaints Commissioner - Scalabrini Village Complaints


From: DONNELLY, Margaret [mailto:Margaret.DONNELLY@agedcarecomplaints.gov.au]
Sent: Friday, 23 November 2018 9:21 AM
To: 'bodyartist@bigpond.com'
Subject: FW: Aged Care Complaints Commissioner [SEC=UNCLASSIFIED]

Hi Eva

This is to advise that I will be unavailable from today till the New Year.

Once you have reviewed the issues, could you please respond to my manager: fouad.aswad@agedcarecomplaints.gov.au.

Regards,
Margaret

From: DONNELLY, Margaret
Sent: Wednesday, 21 November 2018 3:03 PM
To: 'bodyartist@bigpond.com'
Subject: Aged Care Complaints Commissioner [SEC=UNCLASSIFIED]

Dear Eva

Further to our phone conversation today, could you please advise if the following adequately summarises your concerns:

1: Concern that the service did not monitor and manage Mrs Luigi Cantali's diabetes appropriately as his BGL readings during respite were elevated and his insulin shots were given in the same direct spot which gave my father a large bruise on the stomach and leg bandages were wrapped very tightly on a number of occasions and all wet with urine. On some occasions my father had open wounds and no bandages on at all.
Desired outcome: that the service confirms with supporting documentation that Mr Cantali's diabetes management was appropriate. I asked for a copy of his BGL readings as I wanted to ensure that his insulin was appropriately managed as he was on a very high dosage and I did not receive a report. I also had to bring my own bandages from home.

2: Concern that Mr Luigi Cantali injured his hand when using his walker, however, this was not recorded as an incident and they said the blistered fingers were from a virus he got and prescribed him antibiotics.
Desired outcome: that the service ensures that incidents are recorded as such

3: Concern that the service did not provide suitable activities or exercise for Mrs Luigi Cantali while in respite from 19 October till mid November 2018
Desired outcome: that the service provides activities for all residents including those on respite.
Please provide any corrections as required.
4. My father was expelled from Scalabrini. This was not my fathers fault. They have not explained to my father nor myself in writing about their reasons why he was expelled.

Regards,
Margaret
Margaret Donnelly
Complaints Officer | NSW/ACT Complaints Operations
Aged Care Complaints Commissioner
P: (02) 9263 3892 , 1800 550 552 | E: margaret.donnelly@agedcarecomplaints.gov.au








Dear Doctor James Grealy - Complaint Letter about my father Luigi Cantali





Aged Care Quality and Safety Commission SA State Office - Carino Care Nursing Home


Dear Eva,

Thank you for your time on the telephone on 24 April and yesterday to discuss the concerns you raised with our office on the care provided to your father by Carino Care at Russell Lea.  I advised you that the concerns raised by you have been moved to our resolution where we have commenced an investigative process.

We talked about making slight wording changes to the issues that you have raised. The four issues with slight adjustment, are as follows:

·         Issue 2: Concern that staff did not adequately manage Mr Cantali’s leg wounds.
·         Issue 4: Concern that staff took no action in relation to a fall Mr Cantali had on about 17/12/18, which resulted in him sustaining bruising to his side.
·         Issue 18: Concern that staff did not call a doctor on the night of 15/1/19 regarding Mr Cantali's very low blood sugar level.
·         Issue 19: Concern that staff did not use correct manual handling techniques when transferring Mr Cantali.

As discussed, all the information that you have provided to our office, can be reviewed under each of the above four issues.  Can you please respond with a brief email and confirm that you are happy with the slight changes made to these issues above.

As discussed, I advised you that I have spoken to my manager and Director, who agree that if you have footage that shows staff using incorrect manual handling techniques, that may have impacted on your father’s safety and health, we would like to view them.  Can you please supply those videos to our office by either methods:



Or by postal address

Attention: Elaine Metherell
Aged Care Quality and Safety Commission
SA State Office
GPO Box 9819
ADELAIDE SA 5000

Please do not hesitate to contact me if you have any questions in relation to the slight wording changes, our processes, or if we can assist you in how you forward the recorded videos we have requested from you. 

With Kind Regards


Elaine Metherell
Complaints Officer | WA/SA/NT Complaints Operations Section
Aged Care Quality and Safety Commission
P: 1800 951 822| or E:  complaintsSAWANT@agedcarequality.gov.au
Aged Care Quality and Safety Commission acknowledges the traditional owners of country throughout Australia, and their continuing connection to land, sea and community. We pay our respects to them and their cultures, and to elders both past and present.
















Complaint Letter to The Aged Care Quality and Safety Commission about St Ezikiel Moreno Nursing Home in Croyden Park


Hello Eva,

Thank you for the further information provided below.  As per your last paragraph, I appreciate that you are trying to give as much information as you remember, in support of your complaint that currently sits in my resolution team.

It is important that the Aged Care Quality and Safety Commission processes and the NSW Coroner processes do not interfere with each other.  As previously requested, I would like to discuss with you by phone this week the differences between our scope and processes, and those of the NSW Coroner. 

For the information of the NSW Coroner staff (who you copied into this email), we are conducting a formal complaint resolution process (S19/011868) around three issues relating to the service’s responsibilities under the Aged Care Act and associated legislation.  As per our previous emails, these issues are as follows:

1.          Concern that the service did not monitor Mr Luigi Cantali’s condition and escalate concerns in a timely manner prior to his unexpected death on 27 February 2019.
             Desired outcome: to understand if there were any warning signs that your father was close to death, and if the service should have transferred him to hospital sooner.

2.          Concern that when Ms Eva Rinaldi (you) arrived at the service on the night Mr Cantali died she was told several different versions of the circumstances of his death.
             Desired outcome: to receive the correct details of what happened to your father on the night he died and the actions staff took

3.          Concern that the service did not take appropriate action when Mr Cantali’s BGL was elevated.
             Desired outcome: for the matter to be assessed to determine how your father’s elevated BGL was managed.

As per my email of 12 April, please nominate a day and time when I can call you to confirm expectations and explain the possible outcomes for our process. There is no need to copy my colleague Fouad Aswad into emails regarding the above three issues.

You are of course welcome to provide details of your experiences (separately) to the Royal Commission. I understand the correct email address for Royal Commission submissions is ACRCenquiries@royalcommission.gov.au, and further details about how to make a submission to the Royal Commission can be found here: https://agedcare.royalcommission.gov.au/submissions/Pages/default.aspx.

As above and requested on 12 April, I look forward to talking with you this week about our process regarding the above three issues.  This will allow one of my officers to put your concerns to the provider formally as a first step toward ensuring the service is held to account for any failure in meeting its responsibilities.

Kind Regards,
Bart

Bart Penson
Assistant Director NSW/ACT | Complaints Resolution Group
Aged Care Quality and Safety Commission
GPO Box 9819 Sydney NSW 2001