A rest home failed to provide a gravely ill resident with the appropriate care in the final months of her life, the Health and Disability Commissioner has ruled, meaning the elderly woman did not receive specialist attention in a timely manner.
The rest home and one of its nurses provided the elderly woman with "suboptimal" care throughout her residency, according to the commissioner's report.
Both the facility and its staffer have been found in breach of the Code of Health and Disability Services Consumers' Right for failing to provide adequate care to the elderly woman, who had a number of health conditions and required supervision.
During her stay at the unidentified rest home, the woman suffered multiple clinical events, and her condition deteriorated in her final months, according to the report.
She was transferred to a public hospital and diagnosed with congestive heart failure and a respiratory tract infection, but died just over a week later after being transferred to a private hospital for palliative care.
In the report released on Monday, health and disability commissioner Rose Wall found aspects of the care provided by the rest home were "suboptimal", meaning the elderly and ill woman was not managed appropriately during her stay.
The woman did not receive the specialist care she required in a timely manner, the commissioner said, and a registered nurse failed to complete the necessary assessments and care plans for the rest home resident.
The nurse also failed to respond to file notes regarding the woman's concerning symptoms, the commissioner noted, and did not alert a GP to the woman's deteriorating health in a timely manner.
According to the report, the manager of the rest home did not provide the appropriate supervision, did not retain copies of relevant clinical records, and misled staff to believe he could provide clinical advice outside his realm of expertise.
The commissioner also found a second nurse at the facility had failed to complete the woman's care plan and assessments in a timely manner.
The Nursing Council of New Zealand will now undertake a competency review of the first nurse on the recommendation of the commissioner. The second nurse's competency and conduct may also be reviewed by the council.
The first nurse has been recommended to undergo further training. Both staffers and the rest home have been asked to apologise to the family of the deceased woman.
As the rest home has since closed, no recommendations could be made regarding the facility's operation and service. Instead, Wall referred the rest home to the Director of Proceedings.