A rest home has been told to apologise to the family of an intellectually disabled woman who suffered serious injuries and subsequently died in 2018.
A report released on Monday by the Deputy Health and Disability Commissioner Rose Wall found Radius Residential Care in breach of the Code of Health and Disability Services Consumers' Rights.
The woman was a resident at Radius Elloughton Gardens in Timaru. One morning, she was found to have a dislocated shoulder and fractures in her left leg, "most likely the result of falling."
The report said despite the injuries being discovered in the morning, an ambulance was not called until the afternoon.
"As she was not able to get in and out of bed by herself, it was most likely that a staff member was with her when the injuries occurred. However, Radius was unable to establish how the injuries happened," the report noted.
"All staff denied having any knowledge of how the woman sustained her injuries and multiple inconsistent recollections were provided".
The Deputy Commissioner found Radius did not provide appropriate care and services to the woman and it is likely that at least one of its staff members was involved in the events surrounding the injury.
"The woman concerned was particularly vulnerable and she relied heavily on Radius Elloughton Gardens to provide her with an appropriate standard of care and keep her safe," Ms Wall said.
"Significant systems issues were present at the rest home which in my opinion compromised the quality of the care provided to her.
"Staff failed to adhere to Radius’s policies, there was a delay in getting the woman to hospital, a pattern of poor documentation by its staff members, and the training provided to its nursing staff was inadequate.
Alongside an apology for the woman's family, a review of all current staff training records and random audits of staff compliance with policy is being recommended.
Wall also recommended the rest home provide an update on its consideration of the external investigator's recommendation that CCTV be installed.
"This report highlights the importance of having a culture that encourages staff to speak up, ensuring that staff follow policy, and of clear and accurate documentation," Wall stated.
She has also referred Radius to the Director of Proceedings who will decide whether any proceedings should be taken.
