The aged care regulator has delivered a scathing report into an eastern Victoria nursing home after an investigation into the death of a resident last year.
Warning: Aboriginal and Torres Strait Islander readers are advised that this article contains images and the name of a person who has died.
In May 2022, 70-year-old Dennis Miller was found dead on the footpath outside the Royal Freemasons aged care centre in Moe.
Questions were raised about the actions the home took after Mr Miller was found unresponsive, whether he was checked overnight, and why photos of the deceased man were taken and allegedly distributed.
Multiple investigations including a coronial review were launched into his death.
An Aged Care Quality and Safety Commissioner (ACQSC) investigation was launched after Mr Miller's family complained, and its report has found multiple failings by the aged care facility.
Staff actions 'deeply disturbing', report finds
The findings in the investigation report were highly critical of the actions of Royal Freemason Moe staff the day Mr Miller was found unresponsive outside his room and covered in blood on the morning of May 15, 2022.
The commissioner reported it was "deeply disturbing" staff waited 21 minutes from when Mr Miller was found at 8:05am until they called an ambulance at 8:26am.
In addition, the commissioner reported staff "did not provide clinical assistance" such as checking Mr Miller's airways or placing him in the recovery position.
Instead, the commissioner found staff went to check if Mr Miller had a do-not-resuscitate order — a medical order instructing that cardio-pulmonary resuscitation (CPR) should not be done if there was heart failure or a person was not breathing.
A do-not-resuscitate order was in place when he died.
"We expect staff would place a resident who has collapsed in the recovery position and check their airway regardless of their resuscitation status, as this is basic first aid," the report said.
The report also noted that basic first aid could have "resulted in a different outcome", however, it was now "a matter for the coroner to determine".
"The action taken by staff falls below the standard of care that a person should expect from an [aged care] approved provider," the report said.
Photos likely taken before ambulance called: report
Another distressing aspect to Mr Miller's family was photographs taken of him and distributed on the morning he died.
The commissioner determined it was likely staff took photographs of Mr Miller prior to calling an ambulance or giving basic first aid.
"[Mr Miller] was photographed face down, indicating photographs were taken prior to the phone call to Ambulance Victoria and to him being turned over for clinical assessment," the report said.
"We do not consider it reasonable that staff took photographs of your father prior to calling an ambulance and prior to turning him over for clinical assessment."
Mr Miller's daughter, Samantha Mowatt, said she was pleased the commissioner had taken her complaint "very seriously" but the actions of the home outlined in the report were "extremely concerning".
"The report details some very concerning deficits in the care that was provided to our dad in the hours before and at the time of his death," she said.
"It's very confronting to read the details and to know they were his final moments."
Report finds lack of monitoring 'may be systematic'
The investigation also found staff "did not appropriately monitor" Mr Miller overnight despite him being given strong prescribed painkillers, having a history of falls, and drinking alcohol the night before he died.
In the 13 months prior to his death, Mr Miller had experienced eight falls and required a staff member to help him stand up from a sitting position because of his risk of further falls, according to his medical notes and notes in the report.
"There were multiple factors that increased the risk of an adverse event, and we are not satisfied [Royal Freemasons] identified and managed the risk," the report found.
It noted "this issue may be systematic" and, as a result, shared its concerns with the ACQSC's Quality Assessment and Monitoring Group, which assesses aged care homes.
The report also found:
- It was unclear when staff saw Mr Miller before his death with conflicting information given to the commissioner, including staff telling Ambulance Victoria he was last seen at 7am the day he died
- A CCTV camera in the courtyard where Mr Miller died "was not functioning" and if it was "would have provided more definitive answers about timing and the events that occurred that day"
Home re-accredited by regulator
The commission audited the Royal Freemason Moe facility in January, and the following month revealed it had failed two of the 44 mandatory quality standards.
This included failing to put in place appropriate risk management for medication administration.
But on February 16 the commissioner extended the home's aged care accreditation for another year.
In a statement, Royal Freemasons chief executive John Fogarty said they were considering the commissioner's findings and would adopt any recommendations from the Victorian coroner's investigation.
"We continue to work with the commission to ensure the safety and wellbeing of residents," Mr Fogarty said.
"As the circumstances of Mr Miller's death are still being investigated by the coroner it would not be appropriate to comment further until these investigations are complete.
"The management and staff at Royal Freemasons remain committed to providing a caring and safe home for all our residents."
An Aged Care Quality and Safety Commission spokesman said they "do not provide specific information about incidents or complaints".
However, after an audit in January the service was "found non-compliant with four of the 42 requirements of the Aged Care Quality Standards in the areas of personal and clinical care and organisational governance".
"In March 2023, the commission made a decision to re-accredit the service until February 16, 2025.
"This is shorter than the three-year accreditation period typically available to services with a good compliance history and means that the commission will return sooner to conduct another comprehensive re-accreditation site audit at the service," the spokesman said.
