Restraining an 85-year-old dementia sufferer several times in 2010 indicated systemic failures at Dunedin's Ross Home and Hospital, deputy Health and Disability Commissioner Theo Baker has found.
The unit is operated by Presbyterian Support Otago (PSO).
PSO development director Lisa Wells told the Otago Daily Times yesterday the incident sparked an organisation-wide review of restraint procedures, and the issues had been remedied.
A new position was created to improve staff training, orientation, and compliance across the organisation.
The commissioner's office did not plan further follow-ups with PSO over the incident, Mrs Wells said.
The man, referred to as Mr A in Ms Baker's report released yesterday, was admitted to the home's secure dementia unit in September 2010, and was restrained with a lap belt at least four times.
He had advanced dementia and was frequently aggressive.
''The fact that multiple staff in the unit used restraint but did not follow the appropriate procedure indicates systemic failures at Ross Home and Hospital,'' Ms Baker said.
Before he was admitted, Mr A's wife asked the unit not to restrain her husband. She was not consulted about its subsequent use.
While family wishes could be overridden if necessary, they ought to be consulted, the report said.
Ross Home breached the patient rights' code through its use of restraint, and through inadequate reporting and documentation, failing to ensure staff communicated with one another, failing to ensure staff evaluated Mr A's progress, or responded to his repeated falls and aggression. The use of restraint also breached the home's internal policy.
''The failure to follow policies demonstrates a culture of non-compliance in the unit, and an environment that did not sufficiently support and assist staff to do what was required of them.''
In addition to the home's breaches, Ms Baker found two registered nurses - one of whom managed the unit - had breached the code. Neither is still employed at the home.
The unit manager, called RN C in the report, failed to ensure correct restraint procedure was followed, and failed to complete and evaluate Mr A's care support plan.
The second registered nurse, called RN D, who had many years' experience, restrained Mr A at least twice without following procedure.
''I accept that, in some circumstances, restraining a person may be necessary. I also acknowledge that in Mr A's case, staff acted in what they believed to be his best interests to prevent him falling, injuring himself or being aggressive to others. However, in using restraint, Mr A's health-care providers were obliged to comply with relevant legal and professional standards,'' Ms Baker said.
The use of restraint could be seen as false imprisonment, Ms Baker said.
Two other staff members' use of restraint attracted adverse comment, but did not constitute breaches, because of lack of training and other support.
Ms Baker said Ross Home had provided evidence it had complied with recommendations to improve systems, processes, and staff training.
