Widespread Failures Exposed: Elderly Woman Found in Chair Covered in Feces

The Health and Disability Commissioner (HDC) discovered significant lapses at a Geraldine rest home where inadequate care was provided to three elderly women.

The HDC report addressed three distinct grievances regarding the quality of care provided by McKenzie Healthcare Limited to the women between 2020 and 2022.

The retirement home stated that they have been working to tackle the problems and enhance both the quality and consistency.

In the document referred to as Mrs A, Mrs E, and Mrs F, it was discovered that the care facility had neglected one individual by leaving her covered in feces and placed another in a dirty bed during COVID-19 quarantine. The latter passed away while remaining isolated.

• Ms B expressed concerns regarding insufficient privacy during her bath time, inadequate attention from caregivers, a perceived disregard shown by both staff members and administration at the establishment, as well as feeling socially isolated.
• The daughter of Mrs E said that when she was isolated during a Covid-19 outbreak, there was a lack of support with hydration, nourishment, and hygiene.
• Mrs F’s daughter brought up concerns about inadequate assistance with bathroom needs and slow response times for the call bell.

The commissioner determined that McKenzie Healthcare was in violation of the Rights and the Code of Health and Disability Services Consumers' Rights for each of the three women involved.

There was no 'reasonable standard of care.'

The HDC discovered that from 2021 to 2022, there was considerable staff movement across both front-line positions and managerial roles, with five general managers among those who left.

The current general manager stepped into the role despite having no previous knowledge of New Zealand's aged-care systems, and did not receive a formal orientation for the job.

The Aged Care Commissioner, Carolyn Cooper, stated following an exhaustive review of all relevant data that she deemed "McKenzie Healthcare failed to deliver a satisfactory level of care for the three residents."

I believe that the level of care delivered in every instance highlighted a systemic issue. Multiple patients experienced consistently subpar treatment, coupled with insufficient organizational frameworks to aid staff in delivering proper care.

Cooper stated, "In my view, this was due to insufficient strong leadership, absence of clear strategy, and inadequate clinical supervision. These issues had a domino effect on healthcare services, leading to an inability to deliver proper care and support for both McKenzie Healthcare employees and their patients."

The current clinical general manager, Jo Fenton, stated to travelcheapwithoutmissingouta that they have considered the report.

"Issues highlighted in the Health and Disability Commissioner's report were both acknowledged and accepted by us. Following this, we've put significant effort into tackling these problems and enhancing the standards and reliability of our services," she stated.

'Stuck in her chair or bed soaked with excrement'

Ms A was a 67-year-old lady suffering from several health issues such as type two diabetes needing insulin treatment, a stomach hernia, and a prior stroke. She had vision loss severe enough to be legally classified as blind and managed two colostomies. Additionally, she frequently experienced urinary tract infections.

Even though a long-term care plan (LTCP) outlined that Ms A required comprehensive help with personal hygiene and toilet needs, including checking and changing her stoma bags at least biweekly—she experienced numerous incidents where they leaked ("blowouts") and found herself left uncared for in her chair or bed soiled with fecal matter. Consequently, this resulted in an infection of her stoma, preventing her from accessing communal bathroom facilities, which placed her in a state of complete seclusion.

The document further indicated that Mrs A was kept in her dirty clothing for long durations, and the absence of assistance from the personnel caused her to leave McKenzie Healthcare prematurely.

The inquiry revealed that there was no short-term care strategy in place when Mrs. A experienced gastroenteritis and was placed in quarantine, and also noted that staff did not receive any official instruction regarding infection control procedures.

The document mentioned that "due to the failure of her colostomy bag leading to fecal soiling, she could not bathe herself. Staff had to attend to her before she could get cleaned up. This situation exacerbated her sense of social alienation and emotional suffering."

'Stretched out on an unkempt mattress with tangled locks'

Mrs E's daughter raised concerns regarding her treatment amid a Covid-19 outbreak in 2022, mentioning that she later passed away following an extended time in isolation where she barely received any notice or help.

In 2020, the individual who was 98 years old was taken into McKenzie Healthcare for receiving healthcare at a hospital level. This person previously dealt with several health issues including glaucoma, dementia accompanied by significant short-term memory loss, impaired vision, physical weakness, inability to tolerate gluten, malignant melanoma, osteoarthritis, and problems with hearing.

When she tested positive for Covid-19 in 2022, Mrs E was placed in isolation for 16 days and was still isolated when she died. The investigation found no reason for her extended isolation.

"No rationale for this extended isolation was documented, and there is no evidence that an assessment was completed at the 7- or 10-day point to assess whether continuing isolation was necessary," said the commissioner.

The resthome told the HDC that other than a low grade fever, Mrs E did not have any other Covid-19 symptoms. When her granddaughters visited her, they found Mrs E "lying curled up in a soiled bed with matted hair, and dry and scaly skin, and it appeared that she had not been moved for some time".

The family mentioned that her false teeth hadn’t been properly set up, making it impossible for her to eat. They also noted there wasn't a straw available for her to consume liquids, and she had been voicing complaints about being hungry.

The report indicated that when Mrs E’s family confronted the staff regarding their insufficient care for her, the staff countered that it was challenging to constantly put on personal protective equipment (PPE), which led them to avoid regular visits and inspections.

McKenzie Healthcare examined their treatment of Mrs E and identified several issues including inadequate communication and record-keeping practices. They also noted an absence of staff training regarding the recording of fluids and nutrition, lack of individualized activities for Mrs E, no coordination with general practitioners, and failure to implement any end-of-life care plans.

'Insufficient staff and a toxic workplace environment'

The third complaint came from Mrs F’s daughter, who expressed concern that the personnel at the retirement home were slow to respond to the call bell due to “insufficient staff and a negative workplace environment”.

Ms F was a 79-year-old lady who moved from McKenzie Village to McKenzie Healthcare for higher level medical attention due to worsening health and reduced capability to handle everyday tasks independently. She struggled with mobility issues and necessitated complete help with all aspects of self-care—such as using the toilet and managing incontinence since she had to go to the bathroom four to five times during the night. Additionally, she suffered from chronic kidney disease, congestive heart failure, and felt constantly tired.

The staff informed the HDC that Ms F experienced varying moods, becoming upset and shouting whenever she was left by herself for over ten minutes. She also reportedly turned hostile with verbal aggression toward the care workers and often alleged instances of mistreatment. These behaviors caused concern among the caregivers regarding being alone with her, possibly causing delays in responding to calls from her bell.

Ms F’s daughter informed the HDC that it would take between one to one-and-a-half hours for someone to respond to the call-bell, which made her feel as though her dignity had been compromised. This call-bell system is managed externally by a separate entity, with each resident at the care facility receiving a pager linked to their designated caregiver. Following discussions during a family conference regarding these delays, Ms F was provided with a registered nurse pager specifically for instances where the regular call-bells went unanswered.

The report stated that no minutes were recorded for this meeting, and there was no indication of any corrective action plans or investigations carried out regarding the complaint.

McKenzie Healthcare recognised that prolonged wait times for the call bell could have resulted from their staff tending to other residents. They apologized for this and insisted that there was no justification for not checking on Mrs F.

The inquiry also uncovered issues regarding the management of Mrs F’s incontinence. According to the document, “the records show inconsistent data entry; some days noted just a single instance of urination, whereas on other occasions, no details were logged at all,” as stated in the report.

Recommendations

The commissioner acknowledged that the rest home had implemented considerable improvements since 2022 and provided several suggestions to McKenzie Healthcare.

The recommendations include:

• An apologetic letter to the women and their families
• Finish your training on interacting effectively with and discussing matters concerning elderly individuals and their families, which includes methods to ensure that alterations in residents' requirements are recorded securely and shared properly. This will help reduce the likelihood of such incidents happening again in the future.
• Full training on supporting individuals living with dementia, including understanding person-centered care, recognizing changes or deterioration, utilizing the STOP and WATCH tool, and fulfilling associated duties in caregiving and communication.
• A review of the modifications implemented to enhance its systems and procedures, as part of an assessed corrective action plan.
• Discuss with the nursing team the importance of accurately recording all concerns raised by the family in the resident's clinical record
• - Supply copies of the certificates showing completion for all present employees regarding HDC’s online courses within half a year from the date of this report.
• - Conduct a review of all call-bell response times and furnish a copy of the updated policy.
• - Supply proof of the caregiving standards it has established and documentation of the caregiver training conducted, all within 12 months from the date of this report.
• Consider seeking support from South Canterbury ARC health experts to strengthen its clinical practice standards, to inform individualised assessment, planning, and delivery of safe resident care

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