Janine Kaiser

“The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability N”

“Records were difficult to interpret and did not accurately record times at which fluid and food had been offered to the deceased. The amounts taken by the deceased were not adequately recorded.”

“Staff appeared inadequately trained in record keeping.”

“There was poor continuity of staff.”

“Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased's records. The staff were inadequately trained in pressure mattresses management. They apparently checked that the mattress had a power”

“Referral to Tissue Viability nurses should have been done sooner.”