Coroner recommends care workers document changes in residents’ health

A Queensland coroner has recommended that personal care workers and assistants in nursing be required to enter any variation in a resident’s condition in their progress notes, following the health-related death of an 86-year-old aged care resident.

The case was reported and reviewed in the November edition of the Victorian Institute of Forensic Medicine’s (VIFM) Residential Aged Care Communique by Professor Joseph Ibrahim from Monash University.

It involved a resident residing in the low-level care section of a residential aged care facility, which had a registered nurse available if called upon by personal care workers.

After the resident notified staff he was unwell on a Sunday morning, he was reviewed by a registered nurse, examined by his GP the following day and died the evening after that.

Following hearing from all parties involved and independent experts, the coroner found there was limited assessment, inadequate communication between facility and medical staff and a lack of recording and reporting of symptoms and considered the resident’s death healthcare-related, according to the review.

The coroner recommended that the residential aged care service:

• ensure that personal care workers and assistants in nursing enter any variation in a resident’s condition in the residents’ progress notes, which should include to whom the matter was escalated and the subsequent assessment and response;
• encourage visiting medical officers to document the diagnosis and management plan, including any planned review and indications for earlier escalation, with enough information to inform nursing staff on every shift what is required and when medical staff or emergency services be contacted; and
• consider further training of personal care workers to enable them to make entries in residents’ records where appropriate.

Considerations for care facilities

Associate Professor Deirdre Fetherstonhaugh, who reviewed the case for the VIFM from the viewpoint of a RN, said there was a number of important issues for aged care services to consider and address in what happened to the resident from the time he experienced the first symptom until he died three days later.

These issues concerned inadequate assessment and examination, lack of documentation, and poor communication between medical, nursing and care staff and possible non-adherence to best practice.

Professor Fetherstonhaugh, who is director of the Australian Centre for Evidence Based Aged Care at La Trobe University, said most direct care to people living in residential aged care in Australia was provided by personal care staff who “know” the resident best as they have the greatest continuity of contact with them.

“These care staff are not nurses; often do not have a clearly defined scope of work; are not registered; and their training and education is highly variable.

“Care staff should however, be able to recognise changes or variation in a resident’s health so that any deterioration can be reported – both verbally and documented in the resident’s record – to a registered or enrolled nurse,” Professor Fetherstonhaugh said.

“Best practice would recommend that a comprehensive health assessment be undertaken with a resident when they first move into residential aged care. This provides a baseline of their health status for comparison if the person deteriorates or presents with new or specific symptoms such as those experienced by the resident,” she said.

Read the review here.

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