August 4, 2019

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.
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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
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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.
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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
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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.
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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