Nurse failed to act over dementia patient’s 27 falls

A NURSE at a South Tyneside care home who failed to act after a dementia patient fell 27 times in the last two months of her life was let off with a caution.

Paula Washington admitted failing to alert a GP to the elderly resident’s condition as she deteriorated and died at St Michael’s View Care Home in South Shields.

The woman’s death was one of 16 to die at the home, which prompted an investigation by police and the prosecution of two staff members.

Washington should have referred the woman, known as Resident A, to the South Tyneside falls team, after she fell 27 times in 66 days at the home.

She also failed to update Resident A’s records and complete, and ensure, staff followed her care plans, even after the pensioner spent six days in hospital with a fractured pelvis.

Washington then failed to monitor or record the woman’s vital signs shortly before she died, the Nursing and Midwifery Council heard.

Dylan Moses, for the NMC, said: “Resident A had difficulty communicating, dementia, memory loss, and a history of falls.

“Staff did not produce an updated care plan for her, after she fell 27 times in 66 days, including five falls in her first eight days at the home. Her falls should have prompted an early referral to South Tyneside falls team, but such a referral was never made.

“When her condition deteriorated, there was no evidence to show the registrant recorded her vital signs or informed the GP. Her GP transferred her to South Tyneside District Hospital and she died later that day.”

NMC panel chairman William Ard said: “The panel considered Mrs Washington’s failures were serious. They were wide-ranging and involved areas of basic nursing care.

“These included failures to adequately complete records and care plans, failures to ensure care plans were followed by other staff, failures to act upon and escalate concerns regarding the wellbeing of patients, a failure to ensure a correct policy was in place and failures to appropriately monitor patients.

“These failures were significant and occurred over a period of time. As a result, several frail, elderly and vulnerable patients were caused severe harm.

“In terms of mitigating factors, the panel considered this occurred in a severely failing home, where there were institutionalised breaches of CQC standards and systematic failings.

“Mrs Washington has expressed genuine remorse for her acts and omissions. The panel also noted her previously unblemished lengthy career. The misconduct involved was serious. It resulted in direct harm to a number of vulnerable patients.

“The panel acknowledged that Mrs Washington has made significant attempts to rectify her misconduct.

“The panel considered whether a caution would sufficiently protect the public, given that it would not restrict Mrs Washington’s freedom to practice in any type of nursing environment.

“Having considered the remediation and reflection undertaken by Mrs Washington, and the fact that a caution order would act as a mark on her registration, and alert any potential employers to the previous misconduct during its duration, the panel was satisfied that it would”, Mr Ard added.

Resident A was admitted to St Michael’s View Care Home in September 2009, where she fell 27 times up until her death in November 2009.

Washington, who attended the central London hearing, admitted all charges against her. Her fitness to practise was found to be impaired and she was handed a four-year caution.

The nurse’s case is one of seven NMC hearings of former workers at the home, which was then run by the company Southern Cross.

Ailsa King was struck off last month for failing to care for an elderly woman who died just a fortnight after she was admitted to the home.

Johnsy Johnson was suspended in June for 12 months, for failing to give an elderly woman potentially life-saving CPR.

The Gazette revealed last week that the home, now owned by Countrywide Care Homes Ltd, is set to close.

Care employee’s catalogue of errors at home

PAULA Washington also failed to refer a second resident to the falls team despite him falling six times in just 15 days.

The man, Resident I, suffered a chest infection on October 6, 2009, yet no care plan was ever written to reflect his condition.

The next day, another nurse found Resident I was suffering from oral thrush and bruising to the coccyx area, yet Washington failed to act upon the issue.

His fluid charts were not always completed and left nameless, meaning they could have been anyone’s, the hearing heard.

Three other residents were unnecessarily given suctioning to clear airways by Washington, when she had not undergone the appropriate training.

St Michael’s View only had one catheter for the suctioning, despite catheters being intended for single use due to infection risk.

Det Insp Ian Bentham, of Northumbria Police, said when he visited St Michael’s View to investigate the deaths, both inadequate suctioning and blood pressure monitoring equipment were found.

“The suctioning equipment was found on the carpet floor and no other catheter was available,” he said.

“During our inquiry, there were an identified number of deaths from chest infections.”

One patient suctioned by Washington, ‘Resident B’, was found by a colleague to be ‘frail and ill looking’ before she died in February 2010.

Another man, Resident F, was left to be nursed in his bed for seven months without ever leaving his room, the hearing was told.

Washington also failed to ensure care plans for him were accessible to staff and failed to maintain his records adequately.

She also failed to ensure a safe environment for the man in that she did not ensure he was being turned regularly.

The nurse also failed to appropriately manage the man’s food and fluid intake and did not ensure that he was suctioned by adequately trained staff.

Source The Shields Gazette

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