The male resident, who was in the facility's Lindsay Unit, its psychogeriatric unit, died in Dunedin Hospital, his condition having deteriorated after the nurse did not follow his treatment plan, Mrs Bremner said. She did not believe the death resulted from the wounds, and said the man had a host of health problems.
The Otago Daily Times reported yesterday the Southern District Health Board (SDHB) and Ministry of Health audited the home after concerns were raised over the man's care. The audit inspection took place during the past fortnight, and the draft audit report was delivered to Presbyterian Support yesterday.
Mrs Bremner told the Otago Daily Times the nurse failed to follow a plan agreed upon by the resident's GP and family.
The nurse, who was in charge of the ward, did not refer the man to a wound specialist at Dunedin Hospital, as had been agreed, and his condition deteriorated over the next 10 days.
The nurse, who had been at Ross Home about four years, showed "poor clinical judgement" in not arranging the specialist appointment.
She did not know why the nurse acted as she did.
Mrs Bremner said Lindsay Unit residents were having individual clinical reviews, which should be completed today.
Mrs Bremner wanted something positive to come out of the man's death, in terms of improving systems and ensuring such an incident did not happen again.
An internal investigation revealed no major shortcomings in terms of systems.
Staff had been spoken to and reminded of their responsibilities. While no system was perfect, residential facilities should never be complacent and must always look for ways to improve, she said.
Ross Home was a "delightful place" with a good atmosphere, and had performed strongly in previous audits.
Yesterday, Mrs Bremner met Lindsay Unit residents' families, a meeting she described as constructive and supportive.
Mrs Bremner said she had not had a chance to read the draft audit report fully, but agreed with its key findings. The audit made it clear that excellent care was provided in other units at Ross Home. she said.
The SDHB and the Ministry of Health have referred the death to the Health and Disability Commissioner.
