The Aged Care Commissioner has found Ruapehu Masonic Association Trust, trading as Masonic Court, breached the Code of Health and Disability Services Consumers’ Rights in its care of a 97-year-old resident during July–August 2021.

In a decision released today, the Commissioner found Masonic Court failed to provide services with reasonable care and skill under Right 4(1) of the Code. The case centred on missed or delayed nursing assessments, gaps in care planning, and limited communication with the man’s family as his health declined.

Mr A was admitted to Masonic Court on 1 July 2021 after a hospital stay for pneumonia. He initially received intermediate care before transferring to long-term care on 22 July.

Key findings included:

• On 14 July, when Mr A’s daughter requested a GP review for worsening respiratory symptoms, vital signs were taken but there was no targeted nursing assessment of his respiratory status, cognition, behaviour or pain. Advice was sought from the local hospital’s Emergency Department, which did not recommend admission. A GP was subsequently contacted and prescribed an expectorant and antibiotics.
• Care plans lagged behind recorded risks. Mr A’s reduced food and fluid intake was noted from 22 July, but a care plan for poor intake was not completed until 10 August. A falls prevention plan was not developed until 13 August despite a fall on 21 July, and his falls risk was not reviewed after a second fall on 12 August. A pressure injury was recorded by a caregiver on 18 July without a corresponding prevention/management plan.
• Records noted a conversation on 22 July with the nurse practitioner and family about “comfort cares when time comes,” and anticipatory medications were charted. Hospice input occurred on 14 August. However, the Commissioner was critical of the lack of documented, ongoing communication with family as Mr A’s condition deteriorated and of the overall nursing care at end of life.

In-house clinical advice from RN Hilda Johnson-Bogaerts described:

• Nursing assessment and management on 14 July as a mild to moderate departure from accepted standards.
• Nursing input during intermediate care as a mild departure.
• RN assessment, care planning, and family involvement/communication during long-term admission and end-of-life care as a moderate to significant departure.

Mr A died in August 2021. Masonic Court acknowledged it did not contact the family after his death and said it should have done so.

The Commissioner has directed Masonic Court to:

• Provide a formal written apology to the family.
• Complete training on the STOP and WATCH tool for recognising deterioration and the ISBAR communication tool.
• Review the files of the last 10 residents who received end-of-life care in the past six months and report findings and corrective actions.

Masonic Court told the Commissioner it has since:

• Implemented electronic clinical records with alerts and notifications.
• Provided hospice education on palliative care and access to training modules on end-of-life care, falls prevention and care planning.
• Set up a designated palliative care room and a retreat room for families.
• Adopted a bereavement protocol that includes contacting families, sending a card and flowers, and having a representative attend funerals.
• Increased RN documentation, with the clinical nurse lead and RNs making regular progress note entries.

Masonic Court did not comment on the provisional report. Mr A’s daughter, Mrs B, told the Commissioner she appreciated the investigation and the changes made, noting the important role facilities like Masonic Court play in caring for older people.

A copy of the anonymised report will be sent to HealthCERT and Health New Zealand | Te Whatu Ora and published on the HDC website for education. The decision was issued by Aged Care Commissioner Carolyn Cooper.