One woman died of an infection after severe injuries were badly handled by a nursing home and infested with worms.
The case is detailed today in a report by a deputy commissioner for health and disability, Rose Wall.
She said the unnamed woman was admitted to a care home run by Care Alliance Limited from a public hospital in 2015. This followed an InterRAI assessment which concluded that she needed long-term care at the hospital level.
The woman, Ms A, had a background of high health demands, including severe peripheral vascular disease, congestive heart failure and type 2 diabetes. She also had a left-handed amputation amputation two years earlier and he was using a wheelchair.
When he went to the nursing home he had ulcers in his right leg and five more wounds developed in the nursing home. Clinical recordings five and six months after entering the nursing home have made frequent comments about his injuries, being smelly or "smelly" during dressing changes, "with varying degrees of exudate" [infiltration].
However, "an assistance plan for the prevention of pressure injuries was not implemented until the eighth month [about six months after he returned home], and there is no documentation to show that there is an assessment in the course of the wounds of Ms A. "
Ms. Wall said that Mrs A suffered considerably from pain during wound reviews and other procedures related to her injuries at the resting place. But "there is no evidence that Mrs A was offered any form of pain relief before dressing her wounds, and there was no specific treatment plan to manage the pain associated with her injuries."
One of his wounds – a pressure wound in the upper part of his left leg – had increased to 6 cm by 5 cm and 1 millimeter in depth, but had not been escalated for revision, no medical input was obtained and no photographs were taken.
Towards the end of her time in the nursing home, Ms. A was "weak but not responding". She was admitted to another hospital where a nurse noticed that there was a "necrotic stump spreading over a knee" that smelled bad and "worms present". The worms were also found in the wounds of the right foot and even the right toes had dead tissue.
Ms. A died soon after due to sepsis or infection with infected ulcers.
Ms. Wall stated in her report that inadequate management of Ms. A's care and injuries by the rest staff led to her transfer to the second hospital. He added: "Upon arriving at hospital 2, Ms. A's wounds were noted in very poor condition and the skin between her fingers indicated a poor level of hygiene."
He said it was of paramount importance that the nursing home staff was attentive to Ms. A's needs and Care Alliance Limited had violated the patients' rights by failing to do so. Instead, Ms. A's injuries "were allowed to progress to a level that would be significantly infected. Furthermore, it is worrying that Ms. A would have experienced significant pain with the deterioration of her condition, which she could have be avoided if his pain had been more effectively managed ".
Wall noted that in March 2017 Care Alliance Limited sold the rest home to a new owner. "The two companies do not share any connection. HDC requested further information from the director of Care Alliance Limited, who stated that he did not have relevant information on the nursing home because he no longer had his laptop in which the information was stored , or information stored elsewhere ".
This meant that the HDC report had to be based on incomplete information provided by other parties.