Inside Australia's Nursing Homes: A New Online Tool
By Joel Tozer, Sharona Coutts, Clare BlumerMarch 8, 2012
The Global Mail has created a new online tool for consumers to check the oversight records of hundreds of aged-care facilities.
George Hadgkiss lies in a hospital bed, tubes inserted through his nostrils, vivid bruises purpling his jaw. His family surrounds him, filmed from the shaky, invisible hand of one of his children, who is holding the camera. The video shows the 85-year-old World War II veteran in obvious pain as he labours to answer his children's questions about the incident that landed him in Royal Brisbane Hospital, needing surgery to repair three fractures to his jaw.
A black-and-white x-ray sheet pops up in front of the camera. One of the family members holds it up, as evidence of what they say happened to their father. It shows three clear spots of bright white, indicating fractures in the bone.
George Hadgkiss's Story
"Dad, can you tell me what happened?" asks one of his daughters.
The old man recounts being startled by an aged-care nurse at the nursing home, where Hadgkiss had been living for several weeks. According to the Queensland Civil and Administrative Tribunal, which dealt with a claim of professional misconduct, the nurse had crouched down to check Mr Hadgkiss's ventolin nebulizer. Startled, the 85 year old responded by placing his hands on or around the nurse's throat. The nurse's response was to push against Hadgkiss's jaw and in doing so, the tribunal notes, the injuries were caused.
"He punched me," claimed Hadgkiss, in the video. "Stupid thing to do to an old patient."
The Tribunal noted that there were other ways the nurse could have dealt with the situation. There was a substantial physical discrepancy between the two and that "the patient was vulnerable and suffered from conditions which should have put the nurse on alert about how he should be approached," the tribunal found, and concluded that the nurse's response to Hadgkiss demonstrated a lack of adequate knowledge, skill, judgment or care in the practice of his profession.
The Global Mail's efforts to contact the nurse were unsuccessful, but the family says the case points to what can happen when there are failures in the system meant to protect people in aged care.
"I've worked in a nursing home as an assistant nurse," says Susan Hadgkiss, one of three Hadgkiss children who spoke with The Global Mail. "I see how vulnerable they are. If families aren't coming around, who's protecting them?"
The children point to several elements of their father's case that they say illustrate broader problems in the system. For one, they complain that there was a seven-year delay between when the events occurred and when the tribunal handed down its decision to reprimand the nurse and impose conditions on his registration. They are also troubled by the tribunal's finding that the nurse failed to formally report the incident. And they note the absence of any record of the events on the official websites - the Department of Health and Ageing and the Aged Care Standards and Accreditation Agency - that are supposed to provide transparency and accountability in Australia's aged-care facilities, the technical term for what are better known as nursing homes and hostels.
George Hadgkiss died a year later, from conditions the coroner said were unrelated to the injured jaw. His family says their father never recovered from the physical and emotional shock of that event.
"The trust in fellow man was all gone" says Tina Houldsworth, another of George's daughters.
"I don't want to see another family go through what we've been going through," Houldsworth says.
A new analysis of official reports gives a more complete picture of the problems in aged care
An analysis of hundreds of government reports and official documents by The Global Mail shows that the issues that concern the Hadgkiss family are not uncommon.
Using a range of official documents, we have created an online tool that the public can use to search for aged-care facilities that have breached official standards relating to care performance, according to oversight bodies. The Global Mail will periodically update the online tool as new information becomes available.
Oversight of Australia's aged-care industry is shared by two bodies in the main: the Department of Health and Ageing, and the Aged Care Standards and Accreditation Agency. The two are technically independent, but work closely together to supervise more than 5,000 aged-care facilities, including nearly 3,000 residential facilities, according to government data.
When the department finds an aged-care facility to be in breach of its legal duties, it can issue a notice of non-compliance, or a sanction. (The definitions of a "notice of non-compliance" and "sanction" can be found in the glossary of the accompanying data visualisation).
Assessment teams from the accreditation agency conduct regular scheduled and unannounced visits of homes, and where they find shortcomings, they will often decide to shorten the facility's period of accreditation. In some extreme cases, they will revoke its accreditation altogether. In either case, the agency publishes a decision to vary or revoke the facility's accreditation. Only accredited facilities are eligible to receive government funds.
Taken together, these documents comprise most of the publicly available information about problems at specific aged-care facilities. An analysis of the documents gives a sense of the biggest problems identified by officials at facilities across the country.
Those problems include:
- Inadequate staffing - including training and staff shortages - were found in more than half of the homes that received negative reviews from the accreditation agency;
- Residents were often left waiting hours for assistance with their toileting, or endured other continence-related problems;
- Several facilities failed to report assaults, including assaults on residents by staff, or by other residents.
The online tool will give consumers more information about the quality of aged care in Australia and will encourage providers to improve their standards, according to John Braithwaite, a research fellow at the Australian National University, who in 2007 published a book on regulating aged care. "It's going to contribute to quality of care," he says.
Consumers need better information about nursing homes, expert says
On paper, at least, Australia has a high-quality system of aged care. Nearly 95 per cent of nursing homes satisfied all of their accreditation benchmarks, as at December 31, 2009, according to Chris Falvey, general manager of corporate affairs at the accreditation agency.
Indeed, experts, workers and family members of aged-care residents told The Global Mail that many facilities provide very good care, and that the majority of aged-care staffers work extremely hard, often for relatively low wages.
However, some argue that it's unrealistic to suggest that nearly 100 per cent of the aged care facilities in the country are performing perfectly.
"It's absolutely not believable," says Braithwaite. He says that giving virtually all homes perfect reviews doesn't help consumers distinguish between them. "It's just a farce if the system is partly about giving consumers meaningful feedback on which places are better or worse." A more gradated, detailed system would be of much greater use to consumers, and spark professionals to improve their performance, he says.
The government possesses a wealth of information about the quality of aged care, in addition to the information it makes public. For instance, the department receives thousands of complaints each year, which are not published because of privacy and other legal constraints. And though it publishes the fact that a sanction has been imposed on a home or provider, it provides only a vague summary of the breaches involved. For example, it might say, "Accreditation Standard 2: Health and personal care," and itemise shortcomings such as, "Clinical care", "Other health and related services" and "Medication management".
Additionally, the department issued nearly 400 "notices of required action" to aged-care facilities in 2010-11 alone. Those documents, which the department provided to The Global Mail, noted failures relating to assaults, police checks of staff, inappropriate restraint of residents through both drugs and physical means, and one failure relating to "respect and dignity for the dead." However, the department did not include the facilities' names on the documents, so it is impossible to know where these problems occurred.
Even when information is published, it often disappears from official websites after a certain period of time. The department typically removes notices of non-compliance after two years, while the agency takes down decisions to vary or revoke accreditation from its website as soon as an updated review is published.
Many people we spoke with said residents and their families are often reluctant to speak up about problems in nursing homes, for fear of retribution by staff or management, and that numerous problems go unreported as a result.
Nevertheless, it is clear from the reports that are available, that some issues have emerged as widespread problems in nursing homes and hostels across the country.
Staff shortages affect residents' health and safety, and staff morale
One of the most common complaints against aged-care facilities is a lack of adequately trained staff.
"We are currently 20,000 nurses short in aged care," says Lee Thomas, federal secretary of the Australian Nursing Federation. "Our workforce is imperative to aged care, to keep it functioning," she says.
That shortfall could increase dramatically along with demand for aged-care services.
Our analysis shows that more than half of the facilities that had a negative accreditation review between July 2008 and the end of 2011 failed one of the criteria relating to staff education and training. Within the agency reports, assessors described a lack of qualified nurses to oversee medication or medical procedures, or staff complaining that they did not have sufficient time to perform their duties.
The exodus of workers from aged-care nursing has become a primary concern for Terri Burrell, a registered nurse who works as a supervisor in an aged-care facility in Ashfield, a suburb of Sydney. Burrell is an unpaid union representative.
"In my facility, from 8.30pm to 6.30am, there's one registered nurse and two assistants-in-nursing for the 59 residents," she says. Many elderly people who suffer dementia are prone to walking around at night, and Burrell says ensuring their safety can present overwhelming challenges for nurses who also have to attend to regular duties such as turning immobile residents in their beds, to prevent bedsores. "I could have five or six wanderers, on a bad night. And you've got three staff. How could you be answering buzzers, doing the hourly rounds you need to do, and turning people?"
Burrell and other nurses told The Global Mail that the grueling work, combined with wages that are below what nurses can earn in public hospitals, has left the industry searching for ways to fill the staffing shortages.
One solution has been an increased reliance on so-called personal care workers, according to Jean Booth, a lecturer in nursing at La Trobe University. While registered nurses usually have tertiary qualifications, and enrolled nurses have undertaken a TAFE course of about 18 months, Booth says it is possible to gain a qualification as a personal care worker in as little as six weeks.
Leaving registered nurses with a team of minimally trained workers can put both residents and nurses at risk, and Booth says it's not uncommon for nurses to be responsible for upwards of 60 residents at a time. "If they've got untrained people working for them, they might not report things or see things that a registered nurse would see."
According to a 2009 report by Access Economics, there were nearly 85,000 personal care workers in Australia in 2007, accounting for 64 per cent of the aged-care workforce. That percentage was expected to grow substantially over coming years, the report found.
The increased reliance on workers with minimal training is a cause for concern, according to Henry Brodaty, professor of ageing and mental health at the University of New South Wales, and one of Australia's foremost authorities on dementia. "People in nursing homes have more complex medical needs, but the staffing hasn't kept pace with that," he says. "Many have minimal training."
Unlike most healthcare workers in Australia, personal care workers are not subject to formal registration. The federal Treasurer, Wayne Swan, announced a commitment of $3.5 million in the 2010-11 federal budget to explore registration of personal care workers. The Department of Health and Ageing told The Global Mail that they have engaged a consulting firm to look at the issue, and expect a report in the coming months.
For one Queensland family, closing that gap in regulation has taken on the hues of a crusade, after their 89-year-old mother was allegedly assaulted by a worker at a nursing home in northern Queensland.
Due to the sexual nature of the alleged assault, The Global Mail has agreed to withhold the identity of the victim and her family. They provided us with documents to back up their story, including correspondence with the Department of Health and Ageing, and an April 2010 decision by the federal Aged Care Complaints Investigation Scheme which determined the home had failed to "ensure a safe environment for residents," and referred the matter to the department for further consideration.
The events occurred in July 2009, several weeks after the woman moved into the facility, which is run by one of Australia's largest not-for-profit providers of aged-care services. Her daughters visited regularly, and each noticed that their mother's demeanor had begun to change.
"She was very clingy and frightened as the night approached," the sisters wrote in an email statement to The Global Mail. "Whichever one of us was there as evening approached had to check the windows were locked and reassure her she was safe."
The sisters began exchanging text messages and phone calls in which they noted some comments their mother had started making, which they found "odd".
The comments included: "Was she getting married; was she having a baby; not wanting to be disloyal to her husband," the sisters said. She also told them there was a "man that comes in at night and damages women".
As their mother's distress grew, so too did the daughters' concerns, but their attempts to decipher the clues were frustrated because of their mother's waning cognitive functions - her dementia meant she simply couldn't articulate what had happened to her.
Then, on July 31, 2009, a manager from the facility phoned one of the sisters, telling her that a personal care worker had been "immediately stood down" after two alleged assaults on her mother. The sequence of events is detailed in the complaints investigation scheme's findings, which also noted that the worker had earlier been transferred from another section of the facility for "performance reasons" but that "no additional performance management strategies were implemented".
In notes she took at the time, one sister wrote that the alleged conduct involved a "kissing incident" and that their mother had bruising to her upper thigh.
The allegations were referred to the police, but the woman's dementia meant she would not be considered a reliable witness, and police could not pursue the case.
For the sisters, the episode was not just a personal matter. They have come to believe that the absence of registration for personal care workers means that a significant aspect of aged-care lacks proper safeguards for the public.
They say that even though personal care workers are subject to police background checks, that isn't a sufficient safeguard, because of the very high burden of proof required for criminal sanctions.
They have written letters to the department, the federal Aged Care Commissioner, the Australian Nursing Federation, and the Nursing and Midwifery Board of Australia to make their case about registration.
"Personal care workers' role requires the most intimate touching of individuals in their care," they wrote in their email to The Global Mail. "If there was a National Registration Board, as there is for most health professionals under [the Australian Health Practitioner Regulation Agency], there would be a structure for redressing unethical practice when there is evidence of misconduct."
Residents left in soiled continence pads for days at a time, staff forced to reuse pads.
In about a third of all the reports which resulted in the accreditation agency either shortening or revoking a home's accreditation, assessors found that homes fell short in managing residents' continence.
"Urinary tract infections are not monitored to identify trends and residents at risk of recurrent infections," said a report on a Northern Territory facility in April 2009.
At a Queensland facility, care plans did "not provide staff with clear direction to implement toileting regimes, resulting in increased episodes of incontinence," a December 2008 report noted. And in October 2011 assessors at a facility in Brisbane found that assistance to toilets and changing continence aids were not provided "in a timely manner".
Nurses told The Global Mail that continence management is one of the most pressing issues in aged-care facilities because of the effect it can have on the dignity of residents and staff. Many nurses spoke on condition of anonymity, pointing to clauses in their contracts that forbid them from discussing their work with the media.
Nurses complained in particular about rationing of continence pads - which resemble adult diapers - to three per day for each resident.
"Sometimes you did have to put a person back in soiled pads," says Victoria, who insisted on using only her first name. Victoria worked at a for-profit facility on the northern NSW coast until late October 2011. "They wonder why so many people get rashes. It's because we don't have enough pads allocated throughout the day for them."
Another nurse, who works at a not-for-profit facility in Queensland, says some residents turn their pads around after soiling them, because they are not provided with fresh supplies. One resident was left in the same pad for 24 hours before the nurse found him.
"I felt absolutely disgusted and sorry for the poor man," she says. "It was like extreme nappy rash. The skin was all burnt. And it was physically visible that he'd suffered burn from the pad because it had been left on for so long."
Lee Thomas, federal secretary of the Australian Nursing Federation, was taken aback by the accounts of rationing and reuse of pads.
"The accreditation agency is able to be contacted where there is suspicion of substandard care being delivered through fiscal tightening or any other mode," she said.
A department spokeswoman said, "the government provides financial subsidies to aged-care homes on behalf of each resident, based on their assessed care needs, which includes their need for support with continence." How that money is spent is a matter for each home, the official said in an emailed statement to The Global Mail.
Regulators seldom force the closure of troubled aged-care facilities
Despite the problems identified at these homes, regulators very seldom force the closure of aged-cared facilities. Of the 138 decisions from the accreditation agency, we found only two instances where accreditation was revoked, leading a home to close.
"We believe it is in the best interests of residents generally to work with the home to improve the quality of care and services," says Falvey, the accreditation agency's general manager of corporate affairs, in an emailed statement.
"For each resident, the aged care home is their home," he said. "They may have chosen that particular home because it is located close to family and friends so that they can conveniently visit. If the home closes, then this has a major impact on the lives of residents who must find another place to live."
Moreover, Falvey told us the issues identified in accreditation reports "are not indicative of the industry's performance more broadly".
"Each report reflects the particular circumstances at the given home at the time the audit was conducted, and the reasons for failure are also peculiar to that home," he wrote in a letter in December 2011.
Experts on regulation disagreed, saying information about a home's compliance history will help consumers who are considering an aged-care facility for themselves or a family member, and improve transparency overall.
"It's a good idea to give consumers information as to which nursing homes are better than other nursing homes," says John Braithwaite, of the ANU.
"So consumers can see, 'Oh here's a home that has never ever been found to be in breach. But here's a home that has been found to be in breach on 17 things in recent years. There are some questions I need to ask of the management of the home, before I put my mother in there, as to why the breaches occurred, and whether they are likely to occur again.'"