The Aged Care Commissioner’s decision, issued yesterday, said rest-home Clutha Views "departed from an appropriate standard of care".
The commissioner criticised the rest-home’s GP for the "initial error" of administering a 50mcg fentanyl patch on the 92-year-old woman on a daily basis instead of every three days, but also felt the staff should have been alert to the error.
"While there is individual accountability for these omissions ... in my view the continued repeated omissions of several staff responsible for the incorrect fentanyl administration and documentation ... is to some extent a systemic and organisational issue, for which ultimately Clutha Views is responsible."
The decision did not name anyone involved in the incident, including the 92-year-old woman, and did not provide dates when this incident occurred.
"The documentation regarding when the woman’s patches were administered to her was inadequate — details such as the location of the patch, and the date and time on which it was applied and removed, were not recorded either on the patch itself, in Medi-Map, or the woman’s progress notes.
"Due to the poor documentation, the exact dose of each of the fentanyl patches found on the woman is not clear.
"I consider that Clutha Views failed to provide services to the woman with reasonable care and skill."
The commissioner also acknowledged that the woman died during the investigation.
"I offer my condolences."
The woman had been experiencing long-standing chronic sciatic pain and was on regular pain relief that included fentanyl transdermal (skin) patches, along with as required OxyNorm capsules.
Her regimen to manage her pain was paracetamol 1g three times a day, and fentanyl patches to be changed every 72 hours.
The fentanyl regimen was not synchronised, and so the patches were changed on different days.
The commissioner criticised the way the changing of patches was handled.
In the incident investigated, the woman was eventually transferred to hospital after she reported to rest-home staff that she was not feeling well and had a "burning sensation" over her body and had been unable to sleep for the last two nights.
A doctor noted that the woman’s symptoms of insomnia, nausea, and right leg spasms "improved with decreasing the fentanyl dose".
The doctor stated that on admission to the hospital, her fentanyl dose was decreased to 25mcg every 72 hours, and her symptoms of fatigue and confusion resolved with the lower dose of fentanyl, and she was able to be discharged back to Clutha Views.
The doctor suggested to the commissioner that "the nursing staff had inadvertently continued to apply (or more likely had left in-situ) the discontinued 12.5mcg and 25mcg patches supplementary to the revised prescription for the 50mcg/hr fentanyl patch".
The commissioner allowed the granddaughter to read the summary before the findings were published.
She said the fact it took so long to seek appropriate care for her grandmother "haunts me to this day".
"I will never forget what it was like to see her having withdrawals from this drug and lack of care."
Heritage Lifecare, which owns Clutha Views, said it accepted the commissioner’s findings and had no additional comments to make.
The recommendations included providing "evidence that this incident has been used in educational sessions", and training on how to manage fentanyl transdermal patches.
"In the provisional opinion, I recommended that Clutha Views Lifecare and Village provide a written apology to the woman’s family for the issues identified in the report. Clutha Views Lifecare and Village has provided this apology to the commissioner, and it will be forwarded to the family."
