An Oamaru rest-home, under a previous management, has been faulted for its care of a patient, after an incident in 2013 when staff did nothing about a woman who brought in morphine from home to give to her terminally ill mother.
Deputy Health and Disability Commissioner Rose Wall this week released a report in which she questioned the competency of two nurses at Rendell on Reed, then operated by Seniorcare Asset Management Ltd, who did nothing to stop the daughter or alert staff or doctors that non-prescribed medicine was being given.
Rendell on Reed Lifecare Ltd assumed responsibility for the operation of the rest-home in April 2014 and yesterday said staff involved were no longer employed at the home.
According to Ms Wall's report, the 57-year-old patient had advanced pancreatic cancer and was in severe pain in the days leading up to her death in 2013.
Ms Wall said during this time no-one at the rest-home completed pain evaluation/assessment charts, or performed any formal pain assessments as required by the pain management policy, and the registered nurses did not report any ''areas of concern'', contrary to Rendell on Reed's palliative care policy.
The woman's daughter brought a bottle of morphine elixir to the rest-home and told a registered nurse that she would administer it to her mother herself if the nurse would not.
The registered nurse did not inform any senior staff member, management, the hospice or a GP of the incident.
Ms Wall criticised the home and clinical nurse leader at the time for a consistent pattern of inadequate and inappropriate documentation.
It was also held that the rest-home failed in its responsibility to ensure the woman received care of an appropriate standard, as it failed to ensure its policies were adequate and followed appropriately by staff.
She recommended the rest-home update its medication policy, provide palliative care training to all registered nurses, and train staff on the importance of comprehensive documentation, including communication with family.
The Nursing Council of New Zealand should also consider conducting a review of the competence of two of the registered nurses.
The clinical nurse leader, registered nurses and the rest-home were asked to provide written apologies to the woman's family.
''While I acknowledge that individual registered nurses are responsible for their own actions and omissions, Seniorcare had the ultimate responsibility to ensure that [the patient] received care that was of an appropriate standard and complied with the Code,'' Ms Wall said.
Facility director Paul Renwick, from Rendell on Reed Lifecare Ltd, the new operator of the home, said quality and risk management systems had been implemented since then, including using new care planning and assessment tools.
''Two registered nurses have attended palliative care masterclasses provided by Hospice NZ. Staff have access to support and advice from the local palliative community care team.''
Pain assessments were completed as part of a new assessment process and registered nurses ensured GPs prescribed adequate pain relief for residents and that adequate stocks were held for individual residents.
Mr Renwick, of Wellington, is a director of HIL Management Services Ltd, which bought the home in April last year.
