Abuse, neglect and death: Inside the nursing home from hell
An elderly man was bashed to death and another resident died of a morphine overdose at a nursing home of horrors, which removed call bells and denied critical medical care.
Queensland's Coroner is investigating the death of a resident at the Japara Noosa nursing home on Queensland's Sunshine Coast.
Government inspectors discovered "multiple assaults between consumers, causing injury and death'' at the home and declared residents to be at "immediate and severe risk''.
"Incorrect morphine medication was given to one consumer (who) received three times the dose they were prescribed,'' inspectors from the federal government's Aged Care Quality and Safety Commission (ACQSC) reveal in a new audit report which triggered an apology from Japara to residents and their families.
"The consumer was receiving end of life care and passed away 90 minutes after the incorrect dosage of morphine was administered.
"One consumer experienced six falls in seven months.''
The ACQSC inspectors found that one resident with "aggressive behaviours … continued to assault other consumers and staff''.
A spokeswoman for Japara Aged Services Pty Ltd said yesterday a resident with late-stage dementia had assaulted two fellow residents late at night in October 2020.
She said police were called immediately and all three residents taken to hospital, where one victim died shortly after and the man with dementia later died of his condition.
Despite the abuse and neglect uncovered in its audit, ACQSC failed to impose any financial sanctions on the privately-owned nursing home, which is still allowed to take in new residents.
Instead, ACQSC cut short Japara's accreditation until September this year, and demanded that it train staff in "safe and effective clinical care", including the basics of wounds treatment, medication management and palliative care.
Japara was also required to appoint an "adviser'' for six months.
Queensland Health Minister Yvette D'Ath yesterday blasted the "shocking'' allegations of neglect.
"I urge the Commonwealth aged care regulator to do everything possible to protect these vulnerable residents,'' she told The Courier-Mail.
Federal Aged Care Minister Richard Colbeck yesterday intervened to seek personal assurances from Japara chief executive Chris Price and the ACQSC that "appropriate action has occurred to ensure the safety of residents at the facility''.
"I am deeply concerned about the allegations relating to Japara Noosa Aged Care Facility,'' he told the Courier-Mail.
"I have enquired to ensure all appropriate notifications to police as appropriate were made by the provider.''
The Japara spokeswoman said the company had become aware of the problems a month before the ACQSC audit and "apologised to residents and their families for the shortcomings''.
"Care of our residents is our number one priority,'' she told The Courier-Mail yesterday.
"When the extent of the issues became known to us, a month before the ACQSCA became involved, we pulled together senior Japara resources from across the country to start overhauling the care provided to our residents and the physical environment in our home.
"We fully acknowledge that we had not been meeting our own standards.''
The spokeswoman said Japara had hired extra senior managers to focus on residents' care.
ACQSC commissioner Janet Anderson said the watchdog would carry out another audit before deciding whether to extend Japara Noosa's accreditation beyond September this year.
"The Commission is aware of one death following an assault of a consumer by another consumer at Japara Noosa residential aged care service in October 2020," she said.
"The Commission has been advised the Queensland Coroner is investigating the matter.
"Criminal investigations or prosecutions are matters for the police."
Japara failed every one of the eight regulatory standards - including personal and clinical care - in an unannounced five-day ACQSC audit in October, with the results released only weeks ago.
ACQSC inspectors observed staff at the Noosa nursing home "deliberately ignoring a consumer's request for assistance, yelling at consumers, removing call bells, and the provision of hygiene cares without shutting doors''.
One resident died in pain as "pain management processes were ineffective, and the consumer was not kept comfortable for a month preceding their death''.
Another resident who suffered from pain was not seen by a doctor for the duration of their stay, and died in hospital five months after entering the Japara nursing home.
The shocking audit found evidence of staff ignoring doctors' orders and nurses' directives.
"This has resulted in consumers not receiving care which meets their needs in pain management, palliative care, nutrition and hydration, sleep, skin care and pressure injury management, falls and behaviour management,'' the report states.
The declining health of four residents was not reported to doctors, the audit report states, and they suffered infections, pain, pressure sores, and "challenging and aggressive'' behaviours.
The audit found that staff cuts resulted in "rushed and incomplete care''.
Inspectors "observed stained chairs, stained carpet including faecal staining and the malodorous smell of urine''.
"Despite incidents of consumers ingesting chemicals, the assessment team observed the utility room in one wing (of) the service to be unlocked.''
Senator Colbeck said ACQSC had issued Japara with a "notice to agree'', which he described as "a serious regulatory action under which the Commission regularly monitors the facility to ensure notification of any issues on site and the safe provision of care''.
"The Commission will continue to closely monitor Japara Noosa while the requirements are in place, to check issues are being fixed and ensure care recipients are safe,'' he said.
"If Japara fails to take timely remedial action, there are other actions that the Commission may take to ensure the safety of care recipients''.
The abuse and neglect occurred a year after the Royal Commission into Aged Care demanded changes to a "cruel and harmful'' system of aged care in Australia.
Originally published as Abuse, neglect, death: Inside the nursing home from hell