Warrina Innisfail fails spectacularly in report from Aged Care Quality and Safety Commission

A resident of a Cassowary Coast aged care facility who died on the second day of a two-week respite was seen taking unprescribed medications, a report has found.

A resident of a Cassowary Coast aged care facility who died on the second day of a two-week respite was seen taking unprescribed medications and later discovered with empty medication packets in his room, a report has found.

An Aged Care Quality and Safety Commission report published in December also found a woman at Warrina Innisfail was hooked up to end-of-life medication despite the absence of clinical indicators and her saying to staff and her representative that she was not experiencing pain.

The report also found that Warrina Innisfail failed in four crucial areas of the aged care quality standards.

Under the federal government’s new aged care star rating system, introduced just over a week ago, Warrina Innisfail received two out of a possible five stars.

The ACQSC’s report is a separate review, released on December 12 after an audit in early November.

Further problems at Warrina Innisfail included patients waiting extended periods for medications, restraints not being applied in accordance with regulations, and food being poor. Picture: File

Apart from what seems to be distressingly common in aged care homes – complaints of substandard food – the ACQSC report found serious failings at Warrina Innisfail.

In the instance of the respite recipient who died, the report said the individual was “observed ingesting unprescribed medications and was suspected of taking further unprescribed medications when empty packets were found in his room”.

“Administration of medication processes were identified as being unsafe as a medication trolley was left unattended and it was reported the door to the medication room was left unlocked,” the report said.

The ACQSC reported that in the instance of the woman who was administered end-of-life medication, an investigation by Warrina found her mental status, physical function, capacity and condition had been “inaccurately assessed”.

EOL medications can include opioids such as morphine, diamorphine, oxycodone and alfentanil.

The EOL medications were stopped at the request of the woman’s representative, the report said.

Last year Warrina Innisfail completed building a new $20m 60-bed facility. December’s performance report found that one patient died after accessing medications, and another was administered end-of-life medication, contrary to any indications. Picture: supplied

The ACQSC also found staff at Warrina were too busy to read care plans for residents, and could not connect “clinical assessments and interventions” to the effects they had on residents’ wellbeing.

Further complaints reported to the ACQSC included residents saying they had to wait for long periods of time for toilet assistance and for their medications to be delivered, resulting in anxiety and in some cases, side effects such as tremors.

Another criticism was that Warrina Innisfail did not apply environmental restraints “in accordance with regulatory requirements”.

A further identified problem was the unauthorised use of chemical restraint on some residents, and where consent was provided, the risks, benefits and consequences of the restraints were not discussed.

Poor documentation

The AQCSC review of care documentation in the centre identified several instances where residents’ deterioration was not identified and/or responded to.

Documentation for three residents did not contain adequate information to support effective and safe sharing of the residents’ information in providing care, and referrals to other care services were not dealt with quickly enough.

And residents of the home raised numerous complaints over food quality and quantity, including criticisms that meals often lacked taste, portion sizes were too small, and food was hard to chew.

Warrina Innisfail responds

Members of the Board of Warrina Innisfail, including the President of the Board of Directors, Maria Vasicek, were contacted for comment, and Ms Vasicek provided a written response.

“Warrina Innisfail acknowledges the Aged Care Quality and Safety Commission’s recent audit that found a number of areas requiring improvement at our centre,” the statement read.

“The centre is committed to creating a safe and positive environment for residents and their representatives. We have engaged advisors to assist us improve and rectify the areas identified in the audit.

“This work will include additional training for our people, regular progress reports, improvements to our documentation and a review of activities and suppliers to ensure

residents’ needs are met, to the highest possible standard.”

The areas – or standards – where Warrina Innisfail was found non-compliant were:

Standard 2: Ongoing assessment and planning with consumers

Standard 3: Personal care and clinical care

Standard 4: Services and supports for daily living

Standard 8: Organisational governance

Originally published as Warrina Innisfail fails spectacularly in report from Aged Care Quality and Safety Commission