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ROYAL COMMISSION - Focus on serious restraint practices

Day two of the third series for the Royal Commission into Aged Care hearings carried on from yesterday’s case study around physical and chemical restraints used against a particular man with dementia and alzheimers.

Ms Michelle McCulla, daughter of Mr Reeves, outlined the chemical and physical restraints she found her father under while at Garden View Aged Care. [Source: Royal Commission into Aged Care]
Ms Michelle McCulla, daughter of Mr Reeves, outlined the chemical and physical restraints she found her father under while at Garden View Aged Care. [Source: Royal Commission into Aged Care]

In some instances, it was highlighted that the resident, Mr Terry Reeves, 72, was being prescribed multiple dosages of the same psychotropic medication; he was being restrained for long periods of time, including around 13-14 hours; and the aged care facility was not properly documenting, or missing documents, around administered care.

Yesterday, Lillian Reeves, the wife of Mr Reeves, gave evidence of restraint practices being used on him during a respite stay at Garden View Aged Care, in New South Wales, for his dementia starting on May 1, 2018.

Due to technical issues throughout the first hearing day, two other witnesses relevant to that case, Michelle McCulla and Natalie Smith, daughters of Mrs and Mr Reeves, were unable to give their witness statements.

Today, the sisters gave damning evidence of physical restraints being used on him for long periods of time, along with psychotropic medication use to placate Mr Reeves.

Photo evidence of restraints on their father’s limp body sitting in an upright chair brought tears to Ms McCulla during her otherwise strong statement.

Ms McCulla counted up to 30 times when she visited her father and found him tucked away in the east wing of the facility behind a keypad locked door beside other dementia patients who were also restrained in chairs with a lap belt.

One instance of this, Ms McCulla found him hunched over, his head on his chest, and drooling onto a thin singlet he was wearing. The room was cold and he was wearing no shoes.

When Ms McCulla asked a nurse to bath him because he had soiled himself, she was called into the bathroom to help calm him down.

Ms McCulla was confronted with a scene of six nurses “hanging on to him” while one nurse pulled down his pants and Mr Reeves screamed, “no, no, stop it.”

Recalling back to that time, Ms McCulla says it was traumatising for both herself and her father.

From then, the sisters were constantly suspicious that the aged care was mistreating him, restraining him unnecessarily, using psychotropics without permission and potentially not feeding him properly since he was sleeping all the time during the day.

By May 28, Ms McCulla says, “We could see that he was losing weight. He was – you could see it in his face. You could see it on his – like, the way his clothes hung… We were starting to question who was taking the time to sit and feed him while he was asleep like this.

“We also started to bring cooked meals ourselves from home and sit out there and feed him because we were questioning whether he was eating or not.”

Ms McCulla and Ms Smith looked back through his medical charts in June and tallied up the hours he was being restrained, the sister realised that he was being restrained for a horrifying amount of hours, including up to 13-14 hours a day.

Nurses had previously said Mr Reeves was having issues sleeping at night justifying why he was sleeping during the day.

However, Ms McCulla says the chart was suggesting he was being restrained in a chair from 3 a.m. in the morning from one occasion.

Ms McCulla says, “I would have trouble sleeping being restrained in an upright chair.”

In regards to chemical restraints, the sisters only realised Mr Reeves was being prescribed daily doses of risperidone, a psychotropic medication, on May 15, 2018 after they looked at the medical chart.

The sisters were unaware if he was receiving a daily dose before that date. Both Ms McCulla and Ms Smith advised the aged care that they no longer wanted their father being prescribed risperidone.

After a confronting situation on June 17, the sisters were in tears after seeing his condition.

When nurses asked what had happened to their father, Ms McCulla responded, “You tell us, he is no longer the man he was when he came in”.

There were statements from the aged care suggesting the family was happy with the treatment, which Ms McCulla vehemently disputed.

Leaving the facility after ten weeks of care, Mr Reeves’ family say he has never been the same since.

After strong and compelling evidence from Ms McCulla and Ms Smith, a Garden View Aged Care registered nurse, Jayanthi Kannan, took the stand as the third witness of the day.

Throughout her statement and response to questions from Special Counsel Assisting Mr Peter Gray QC, Ms Kannan said she did not recall many of the scenarios provided to her or believed she would not have acted in the way that the family has suggested.

According to Ms Kannan restraints were “only used as a last resort”, but she says the permission sheet for using physical restraints does not suggest how long restraints can be used.

The first case of Mr Reeves found restrained in a chair by his daughter on May 8, Ms Kannan says she was unaware at that time that nurses had decided to restrain him in a chair.

Ms McCulla also could not remember or recollect getting a signature on consent forms to use restraints on Mr Reeves from Mrs Reeves or talking to her about the specifics of when they would use restraints.

The fourth witness in this case study was general practitioner, Dr Miles Burkitt, who attends to residents at Garden View Aged Care one to two times a week.

He talked about the reasons behind his prescription for risperidone and believes a mixture of inadequate communication and assumptions may have been the reason behind overuse of the tranquilliser.

Mr Burkitt says, “These medications are last resort medications. You don’t go flying into it straight away. To be given at the last resort to try and settle a resident down. it is important to take them on a walk through the garden, talk to him, go to the bathroom, get him amongst the residential community.

“Side effects of risperidine, there is a lot listed, in this context, drowsiness and a propensity to fall.

“The dose was still quite low on my prescribing. But elderly people can be very sensitive, medication-like tranquillizers can have a profound effect on some people and minimal effect on others. One has to be careful with the ongoing prescribing.”

Additionally, Mr Burkitt was giving prescriptions of the same drug at the same time as Dr Kenneth Wong, another general practitioner for Garden View Aged Care.

Dr Wong, the fifth witness, agreed with Mr Gray statement that Mr Reeves mobility was good when he entered the aged care facility. He wasn’t considered a risk of falling, but became a falling risk later.

Mr Gray wondered why Mr Wong never considered risperidone was the cause and why he prescribed an additional dose because it seems like an “illogical” move.

Mr Wong says his aim was for the extra risperidone to be used at night so he would be able to fall asleep easier.

During his statement, Mr Wong said he made assumptions early on that he was able to prescribe risperidone after seeing Mr Burkitt’s prescription and comments from nursing staff about Mr Reeves being on the medication before coming to the nursing home.

The ability for nursing staff to make their own judgements about giving medication when needed, or feel it’s necessary, may have resulted in the high level of risperidone sedation.

Next on the stand was the Director of Nursing at Garden View Aged Care, Kee Ling Lau, who gave comment in regards to the use of restraints and said only recently has there been an increase of residents with challenging behaviour.

“The number of residents with challenging behaviour escalated. I recollect that was the peak of restraints we had,” says Ms Lau.

Before 2016, Ms Lau said physical restraints were used very little on residents.

Ms Lau confirmed there is a possibility that physical restraints without authorisation was not being documented by nursing staff and only heard about the extent of restraint use on Mr Reeves from Ms Smith and Ms McCulla’s statement this morning.

The questioning by Mr Gray brought out a confirmation from Ms Lau that the restraint practice policy of Garden View Aged Care may have been broken.

Ms Lau also admitted that one-on-one care for residents is not very affordable, which restricts the care given. The most they could pay for, through the Aged Care Funding Instrument (ACFI) would be a staff member to stay on for an extra four and a half hours.

Over the hearing, it highlighted inconsistencies between proper procedure and what nursing staff were doing with restraints, recorded by the aged care or recorded by Mr Reeves’ family.

Additionally, even direct staff, not nursing staff, were making their own decisions to apply restraints.

Throughout statements from four witnesses employed by/at the aged care, all admitted they had made assumptions they could administer chemical restraints due to nursing notes rather than seek direct permission.

The hearings will recommence on Wednesday, May 8.

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