"Transition Care Program"

The Transition Care Program at Martin Luther Homes at the Basin I felt was strongly sold to us for our elderly parent.

Social workers from another Rehab centre told us there would be great continuity of care and access to allied health, such as Physio, OT and medical doctors being fully aware of our parent's recent past history of falls, MSSA sepsis and hip to knee abscess.

Previous employees at TCP warned us that it is just a holding pen for the elderly and infirm with no stimulation and very little access to extra services, but we were convinced by Eastern Health that our plan to place our parent in respite care at another aged care facility was not the best course of action. 

Over the 6 weeks that our parent was at Martin Luther, it seems they saw the physio 3-4 times in total and I believe had access to the program OT a couple of times. 

The building itself is modern with 2 floors of rather pleasant private rooms with a tiny outdoor area or balcony and a tiny communal sitting room but is completely locked down with residents confined to rooms as there is not enough staff to get any meaningful exercise. 

Consequently, due to a lack of movement (as our parent required supervision as per physio), our parent developed a large pressure sore on their right ankle and a weeping ulcer on their right calf muscle. Requests by our parent for a pillow to elevate their legs in bed I believe was ignored.

The nursing and medical care at TCP, in our opinion, was poor.  My sibling's partner who is a nurse had to ring TCP and ask nursing staff to apply appropriate dressings to our parent's legs.

Alarmingly, the nurse on duty was happy to leave the wounds uncovered for almost 4 days, to when the Doctor was supposed to visit (having already not shown up to see our parent's legs 4 days earlier). The doctor failed to attend and see our parent's worsening legs. The doctor asked the nursing staff to take a photo and send it to them instead. The following day, our parent's lower left leg was weeping copious amounts of exudate from the ulcer and through their skin, so much so, their sock and shoe were wet. We believe this was due to infrequent dressing changes and low absorbent dressings being used.  No pressure gradient stockings or pressure bandage were applied to help with the swelling and poor blood flow. No one instructed our parent to elevate their legs, nor try and increase their exercise to help with blood flow. Swabs were however taken and sent for culture.

I am very surprised given our parent's recent history of sepsis and the very real possibility of MSSA bacteria still being present in their system (due to existence of bilateral knee replacements and spinal cord stimulator), that our parent wasn’t placed on prophylactic antibiotic treatment while the swabs were being cultured.

The following day, the doctor was once again supposed to assess my parent's legs. Later, we discovered the doctor attended TCP failed to see our parent. I believe, probably as our parent was due to be transferred to a different aged care facility the following day.

The next day, our parent was transferred from TCP with a hastily bandaged non-absorbent dressing (ie: sodden exudate sock and shoe) and no pressure bandage, and possibly infected legs. 

At the other aged care facility, our parent's legs were assessed by experienced senior nursing staff as requiring specialised treatment and twice-daily absorbent dressing changes. A Doctor came who decided our parent's legs were indeed infected and commenced antibiotic treatment and tablets to help with fluid retention and the weeping.

Swab culture results a few days after they were taken, showed the leg ulcers are infected with both Staph aureus and Pseudomonas, requiring targeted antibiotic treatment and long term management.

Overall, we felt our experience of TCP at Martin Luther Homes was very poor. I believe there is an insufficient amount of experienced staff who are unable to handle and recognise potentially serious issues which I believe severely compromised the care my parent received. Based on my observations, it seems patients have nowhere to go and not enough staff to help them remain mobile. There was a breakdown somewhere in the system where my parent failed to receive appropriate medical care.

I feel that my parent would not be in the position they are in today if they had gone to the other aged care facility in the first instance, rather than TCP. I will definitely not take my parent back to Martin Luther Homes as a TCP facility.

I believe TCP as a program should have its medical oversight reviewed and overhauled to prevent a similar situation for other frail elderly patients.

In my opinion, there is something wrong with the system.