Provision of care to intellectually impaired woman in residential care

The Deputy Health and Disability Commissioner investigated the care provided to a woman at a residential facility for people with physical and intellectual impairments, governed by the Mary Moodie Family Trust Board Incorporated (the Board).

The woman had an intellectual impairment, autism, epilepsy and was limited in her ability to communicate. A caregiver dragged the woman across the floor by her legs and then by her arms, causing carpet burns to the woman’s back. The caregiver had little training in the management of the residents and the policies in place at the facility were inadequate.

At the time of the incident, the manager of the home was in a personal relationship with the caregiver who dragged the woman. In response to the incident, the manager inspected the woman’s carpet burns, made a doctor’s appointment, spoke with a staff witness, advised the caregiver how to better manage such a situation in the future, and spoke to staff about the incident at a staff meeting. However, she did not inform the woman’s parents or the Board about the incident.

The Deputy Commissioner found that the caregiver breached the Code of Health and Disability Services Consumers’ Rights (the Code) because his actions were unkind and disrespectful, and he did not provide services to the woman with reasonable care and skill.

The manager breached the Code because she put the woman at risk of harm by failing to have adequate recruitment processes, orientation and staff training. She also failed to notify the Board and the woman’s family of the incident, and failed to ensure there was an appropriate management plan in place on how to manage the woman’s challenging behaviour. The manager also failed to take reasonable steps to reduce the use of restraint and to ensure that, when practised, restraint occurred in a safe and respectful manner. She therefore failed to comply with the Health and Disability Services (Restraint Minimisation and Safe Practice) Standards (the Restraint Standards).

The Board was found vicariously liable for the manager’s failures to take reasonable steps to ensure the woman’s behaviour management plan was appropriate and to ensure compliance with the Restraint Standards. The Board also breached the Code for its lack of supervision, guidance and monitoring of the manager’s performance, together with the lack of adequate policies, which resulted in an unsafe system existing in the facility.