Effective communication, adequate assessments, and critical thinking vital to ensure quality of care


Deputy Commissioner, Rose Wall has found Golden Pond Private Hospital and a registered nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for poor care provided to a woman in their care, following a serious fall.

A woman in her eighties at Golden Pond Private Hospital (Golden Pond) fell when she was being transferred by a single healthcare assistant via a standing hoist. The healthcare assistant informed a nurse about the incident at the time, but the nurse did not assess the woman for injury or keep clear and accurate records about the incident.

Following her fall, there were several signs the woman’s condition was deteriorating. However, a lack of critical thinking by the staff involved in her care resulted in a three-day delay in assessment of the woman’s injury, and diagnosis and treatment of her fractured left femur.

This case highlights the importance of effective communication between nursing and support staff, adequate assessments following an adverse event, and critical thinking.

Ms Wall noted the woman was highly vulnerable as she was unable to communicate or advocate for herself, and therefore was reliant on others to protect and keep her safe.

“In circumstances where people are less able to articulate their needs or communicate a change in their condition, they are reliant on the registered nurses and support staff caring for them to draw upon both their clinical expertise and robust assessment tools to identify problems and objectively measure their significance.

“It also requires all staff to recognise the importance of escalating issues in a timely manner. It is Golden Pond’s ultimate responsibility to have in place processes and systems that enable the delivery of safe and appropriate care,” says Ms Wall.

Ms Wall recommended that Golden Pond provide its nursing staff with training on documentation and effective handovers, and implement a formal training program for relevant staff, developed in conjunction with Te Whatu Ora – Health New Zealand (previously the DHB), and/or HealthCERT.

She further recommended that Golden Pond undertakes a review of all its clinical policies, procedures, and guidelines, to ensure they are consistent with current accepted practice.

Ms Wall also recommended that Golden Pond provide a written apology to the woman’s family for the deficiencies in care outlined in the report.

Changes have been made by Golden Pond since the events in this case. The Ministry of Health certification audit was undertaken in March 2021 with no areas identified as requiring improvement. Golden Pond was found to be compliant with the Health and Disability Services Standards and was certified for a four-year term, ending 2 June 2025.

“I am pleased to see that a number of changes have been made by Golden Pond since the events.
“In my view, robust policies and procedures in an aged-care setting are basic and fundamental to ensure older people receive appropriate services to their needs. These are vital to ensure staff receive adequate guidance and support to provide safe and effective health services on a consistent basis,” says Ms Wall.

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