The main focus of the day was around the case study of a resident at Brian King Gardens in NSW, who was prescribed medication and moved onto higher pain therapy treatment without consent from the family.
The 84 year old woman with dementia, referred to as Mrs CO, was placed on mirtazapine, a heavy antidepressant and anxiety medication.
Daughters of Mrs CO, Ms DM and Ms DL, gave statements saying they were never aware of the medication their mother was on before they gave consent and that their mother’s GP, Doctor Margaret Ginger, never explained what the drug would do or it’s side effects.
Mrs DL says, “We realised it was a heavy duty drug, I felt that I am not a doctor, so I put my faith in what was happening on their end and they knew what they were doing.”
The drug itself was not administered by the facility until two days after its prescription by Dr Ginger.
Brian King Gardens only received permission to use the drug after it had been administered to Mrs CO.
The reason the anti-depressant was prescribed to the resident was due to a pastoral care worker’s concern for Mrs CO’s emotional wellbeing.
Mrs CO was constantly wandering in an agitated state, crying often, and reliving traumatic childhood memories of abuse as well as the death of her baby son.
After administering the drug to Mrs CO, she went through occasions of unresponsiveness, not opening her eyes or responding to verbal command, and only responding to pain.
On one particular occasion, Dr Ginger assessed Ms CO for what she believes was a mini-stroke but assured Mrs DL that there was no medical reason to take her to the hospital.
Other concerns from the daughters about Mrs CO’s care were around her inability to eat her food and the decay of her teeth, which was highly unusual for their mother who was strict on dental hygiene upkeep.
There was even a case where the facility failed to provide dental hygiene to Mrs CO for four months.
Taking the stand following Mrs CO’s daughters was Richard Farmilo, resident manager at Brian King Gardens, who made the decision to have Mrs CO put on a higher level of care for pain management, but was unable to say who told him she needed a higher level of care or if he saw Mrs CO himself to determine that.
Accusations were levelled at the facility that Brian King Gardens was “ACFI gaming” by providing high-level treatment to residents. This would give the aged care facility more funding to be used on that resident.
Counsel Assisting, Paul Bolster also queried the use of psychotropic drugs used on patients at Brian King Gardens, reading out statistics from 1 July 2018.
At the time, out of 197 residents, 112 of those residents, or 59 percent, were being prescribed psychotropic drugs.
Mr Farmilo says he was not concerned with psychotropics being used on so many residents at the facility and didn’t believe that number was too high.
Mr Farmilo also confirmed that Anglicare, who operates the Brian King Gardens site, does not have a policy around consent for administering psychotropic drugs.
Following Mr Farmilo’s evidence, Dr Ginger took to the stand and explained her reasoning behind the prescription of antidepressant medication to Mrs Co.
She admitted there are tests to diagnose depression in elderly people with dementia, however, she did not do this test with Mrs CO. Instead, putting her straight on medication.
Since there were no notes to use in the future from a depression test, Mr Bolster says that there would not be anyway to check whether antidepressant medication was working on Mrs CO.
Another issue highlighted by Mr Bolster was the amount prescribed. Dr Ginger originally asked for the drug to be used at night for 15 milligrams (mg) and increased to 45mg with a max of 60mg.
Mr Bolster asked Dr Ginger whether a more appropriate starting dose for someone over the age of 80 would have been have of 15 milligrams of mirtazapine, which Dr Ginger agreed with.
Dr Ginger looked distressed when admitting she didn’t know why she provided the 85-year-old woman with such a high dosage of antidepressants and regretted the prescription.
Dr Ginger admitted she had no explanation of prescribing 45mg of mirtazapine without first using any other intervention to help with Mrs CO’s behaviour and was not happy with her medical decision.
Assault is “the norm” for aged care workers
Following the end of the first case study of the day, Kathryn Jill Nobes, a current aged care worker at a facility in New South Wales, took to the stand to give evidence around her own situation in the industry.
Ms Nobes explained the post-traumatic stress (PTSD) she has experienced from assault by residents under her care in a dementia unit, along with the trauma associated with working in the facility where a resident killed another.
Her statement and evidence was provided in hope it would help create better safety for aged care workers.
In many cases, when she talked to higher management about verbal, physical and sexual abuse, she was expected to just deal with the abuse and shrug it off.
“When I informed my in-charge that I had been assaulted by a resident, the in-charge shrugged their shoulders and said 'that's dementia',” says Ms Nobes.
“This has happened on different occasions. I think there was an overriding culture in aged care of simply shrugging it off.”
Ms Nobes described instances of being punched, kicked, threatened and experiencing inappropriate sexual behaviour from residents in the dementia unit.
One case included her attempting to toilet a male resident, who “plunged” his fists into his own faeces and then punched her with faeces covered fists.
The incident that caused her to have PTSD was after being approached by a resident who had recently killed another resident.
At the time they were not aware that he had killed another resident and had assumed from his blood covered knees that he had fallen over. Ms Nobes says, “The resident was holding a walking stick in his right hand, like it was a club. I saw the resident wearing a dark pair of shorts and that he had blood on his knees.
“He was staring intensely into space and his body looked very rigid. I remember thinking that this was typical of his behaviour… This particular resident had a history of violence towards staff.”
While Ms Nobes still works at the facility, she says that work conditions have a serious effect on the quality of care and safety provided to the residents as well as a huge emotional effect on aged care workers.
Hard calls to make around “challenging” dementia residents
A third case study was covered at the end of the day in the hearing, outlining assault and sexual assault among residents at Columbia Nursing Homes, Oberon Village, New South Wales.
Mr Peter Gray QC, senior counsel assisting, addressed the commission in regards to the complexity of the issues relating to dementia in aged care facilities.
“It’s a case study we’re placing before you to illustrate the complexities of the issues
relating to the management of the behaviours of certain residents in residential aged
care who have what are sometimes called challenging behaviours,” says Mr Gray.
The case study allowing freedom of movement of people with challenging behaviour while possibilities of peril or injury increase to an individual with dementia.
The Oberon facility had multiple assault incidents from the same residents, including an altercation that left one resident in hospital.
The daughter of the resident, Mrs DF, said she found her mother, Mrs CA, with a bruise on her lip on June 24 last year, after feeding her cake.
It was only after talking to her sister, Mrs DG, that she found out that her mother had touched clothes of another resident, who hit her in the mouth.
There was another case were Mrs CA had been assaulted by another patient and ended up in hospital.
Marian Anderson, General Manager of Operations at Columbia Nursing Homes, was the last witness of the day to give evidence about the last case study.
She highlighted that the facility had done extensive re-education and re-training in relation to dementia behaviour management issues identified in March 2018.
Ms Anderson admitted that both direct staff and care staff were providing inconsistent documentation and showed a lack of understanding over policies, which is why the facility took steps to fix it.
Mr Gray brought up procedures for registering violent behaviour from residents with dementia, and if more is done to ensure repeat offenders don’t continue getting into incidents.
Ms Anderson says, “I think that residents living with dementia can be very unpredictable, and there was an incident that did occur that, even though all the strategies had been put in place, they did not prevent it.”
In relation to the assault of Mrs CA, Ms Anderson said it is difficult to know when triggers have occurred for a resident since they can be unexpected and spontaneous.
Mr Gray questioned the reasoning behind placing Mrs CA room within the immediate location of two known aggressive residents.
Ms Anderson continued her stance saying, “There's a lot of unpredictability with residents living with dementia. We endeavour to minimise the risk, but I don’t think we can totally prevent the risk.”
The incidents of assault at the facility, while better equipped to handle, was not always able to mitigate the risk of it due to unpredictability from residents with dementia.
The Royal Commission in Aged Care will return for hearings next week on Monday, 13 May.