Pressure sores on an elderly woman's heels and a rash in her groin prompted her daughter to complain about the standard of care she received at Dunedin's Belhaven Rest Home.
A report released by Acting Health and Disability Commissioner Rae Lamb yesterday related to the woman's care at Belhaven between April 9 and October 16, 2008.
A few days after the woman was transferred to a private hospital in October 2008, she died, aged 91.
Belhaven Rest Home director Fiona Grant said yesterday she wished to publicly apologise to the woman's family, and reassure residents and their families Belhaven's management, policies, and procedures had changed as a consequence of the issues raised.
In her finding, Ms Lamb said the level of care provided to the woman by Belhaven highlighted the importance of rest-homes having adequate systems in place to ensure dementia patients received appropriate care.
A year after entering the home, the woman was assessed for dementia care and transferred to the dementia unit.
About two years later, her health deteriorated and she was assessed as requiring hospital level care.
As well as dementia, she had heart failure, renal failure, breast cancer, hypertension, postural hypotension and anaemia.
Ms Lamb found that two nurses at the rest-home, one working as a registered nurse and the other as nurse manager, failed to review the woman's care plan and appropriately document their assessments of her general health, or develop a wound care plan for a recurring groin injury.
The dementia unit's communication book for the period under investigation went missing.
No-one at the home consulted the woman's family about her care, despite this being a requirement of the home's contract with the district health board.
Ms Lamb held that the registered nurse lacked insight into the level of care required, did not fulfil her responsibilities to manage and provide the care appropriately and did not adequately consult the woman's family.
The nurse manager did not provide sufficient oversight and guidance to staff on the care the woman needed, did not consult adequately with her family and did not respond appropriately to the woman's deterioration.
The home failed to provide the woman with reasonable care and skill that complied with relevant standards and contractual obligations.
Since the complaint, the home has actioned all the requirements of a district health board audit and has apologised for the woman's treatment.
Ms Lamb said the case highlighted the importance of communicating with family and involving them in residents' care.
The two nurses no longer work at Belhaven.
Ms Grant said yesterday her family was now involved in the running of the home, including clinical matters.
The failings in the woman's care were not representative of the care received by other residents during the same period.
Such failings would never occur again.
Belhaven was a family business established in 1983 with a solid record of care, she said.
