The decision followed a complaint from November 2021 received by the Health and Disability Commissioner.
In it, the daughter of the patient, who was in her 80s at the time of the events, complained about the care her mother received during her time as a resident at a Presbyterian Support care home between July and September 2021.
"My mum was a living, vulnerable human, that for the first time required major help in her life. I know Mum was nothing to them, but she was our beloved mum", the daughter said to the commissioner.
After investigation, commissioner Carolyn Cooper found the service did not provide an appropriate standard of care to the woman who had multiple long-term and complex conditions.
The woman had been living in an independent cottage within the complex but a fall and injury, resulting in a stay in hospital, necessitated her move into the facility’s hospital-level care.
The woman had congestive heart failure which required oxygen therapy and compression stockings to manage fluid retention in her legs, Ms Cooper said.
Her hospital discharge notes recommended she was to be weighed daily and have her fluid intake restricted to help manage the swelling.
Ms Cooper said the service breached the woman’s rights by not including baseline vital observations, such as her oxygen saturation, which would have informed staff about when to increase her care. She noted poor documentation of the woman’s fluid balance records, and that she was not weighed regularly, nor was there guidance on managing her fluid intake.
"There was no guidance in Ms B’s initial care plan on how to apply, position and remove her compression stockings, nor was there evidence of pain assessment forms and limited documentation of the effects of her pain medication."
She made a range of recommendations which included a formal apology from Presbyterian Support to the woman’s family, as the woman has since died.
Ms Cooper also recommended that the organisation should review its oxygen management and nutrition and hydration policies with a focus on education and staff training, provide HDC with evidence of training for staff on applying and appropriate use of compression stockings, and of evidence of staff training on privacy, infection control and nursing assessment and care plans.
Finally, she advised them to consider putting in place better processes to ensure residents’ needs are met in a timelier manner.
Presbyterian Support Southland director of Enliven Carol Riddle said the organisation acknowledged and accepted the findings.
She said the team had worked hard over the last three years to implement all the recommendations that were outlined in the decision.
"This included staff receiving further, ongoing education and training to make sure this will not happen again.
"We sincerely regret this happened and we unreservedly apologise to the family for the distress caused.
"The care and wellbeing of our residents is our top priority."
