The Aged Care Commissioner has slammed a care home provider after an elderly woman with dementia was physically abused for more than a year by fellow residents.
Despite having 'grab mark' bruising and puncture wounds, the aged care home said her injuries were a result of self-harm.
However, an investigation has found that was not the case and the Ultimate Care Group (UCG), which runs the aged care home, was in breach of multiple rights of the Code of Health and Disability Services Consumers' Rights.
The breaches came to light after the woman's son complained about the care of his mother who had unexplained bruising on her body and face.
The woman, in her 70s, had advanced dementia and from June 2018 to November 2019 she was a resident in the dementia unit at a UCG care home.
On November 1, 2019, the son made a formal complaint, however, UCG concluded that the bruises could be the result of self-harm.
An investigation by UCG found there was "little evidence that other residents [were] involved in any altercation". It said that the woman was at high risk of falls and "sustains bruises very easily just from constantly walking around".
The investigation also found that on several occasions caregivers had found bruising on the woman but her son was not notified.
On December 2, 2020, the son made a complaint to the DHB alleging his mother had been subject to abuse and/or neglect at the care home and that UCG had been untruthful in its response to his complaint.
An independent investigation commissioned by Te Whatu Ora found several of the woman's injuries were likely to have been caused by physical assault by other residents dating back to August 12, 2018.
Between April and November 2019, there were 14 documented instances of injuries, which included bruising to the woman's face and body, puncture wounds (such as from a fingernail), and possible 'grab mark' bruising. Many of these injuries were recorded as "unexplained", and there were four instances of documented assault from other residents.
In addition to the bruising, the woman had lost approximately 8kg of weight while she was in the care home.
The audit team concluded that it was not reasonable to assume that all of the woman's bruises were caused by self-harm.
"I acknowledge the distress caused to [the woman] and her family. [The woman] was a vulnerable consumer who relied on the staff to keep her safe and to report and address any concerns about her safety and wellbeing," Aged Care Commissioner Carolyn Cooper said.
"This did not occur and as a result, [she] experienced repeated injuries over a prolonged period, which may have been preventable if appropriate and timely safeguards had been implemented. This is unacceptable in any residential care setting, and especially in those providing dementia care."
The findings of the investigation report included that despite clear policies and procedures in place, UCG did not respond to the woman's injuries appropriately and failed to take action to ensure her safety.
The report concluded the woman had been passively neglected and the facility had a culture of accepting behaviours of concern between residents that caused harm. It also found that UCG's investigation into the son's complaint did not meet accepted standards for consumer complaint management.
Cooper recommended UCG provide a written apology to the woman and her family, report missing clinical records for the woman to the Privacy Commissioner and use this case as a basis for more staff training on complaints management and the detection and reporting of abuse. She has asked UCG to report on the progress of these recommendations.
UCG has since implemented a variety of measures, some of which include a new electronic residents records system, improved its complaints policies and created a new organizational structure and clinical roles.
An independent audit has since found that UCG's care facility was compliant with its service provision contracts with Te Whatu Ora.
