The Health and Disability Commission (HDC) has found a retirement village failed to provide health services with "reasonable care and skill", following an elderly woman's fall.
The HDC found The Selwyn Foundation was in breach of the Code of Health and Disability Services Consumers' Rights.
A woman in her 80s living independently in an apartment within the retirement village had a fall and was visited by a Resident Services representative.
The representative said the woman could not remember how the fall occurred and did not agree to see a nurse.
When the representative visited the woman again later in the day they found her slumped down in her chair and confused, the report said.
She was unable to move and was complaining of pain in her back so the representative rang for an ambulance and she was transported to the hospital.
The HDC found the retirement home's care of the woman during this occasion was "inadequate" with procedures unclear to staff and its training and monitoring of practice "insufficient".
"There was a lack of policy to guide the representative when he visited the woman and discovered she had fallen and did not recall the events that had occurred, and that primarily Selwyn’s systems were at fault," Deputy Health and Disability Commissioner Rose Wall said.
Wall recommended the Selwyn Foundation and the representative apologise in writing to the woman's family.
She also made multiple recommendations to The Selwyn Foundation to review, update and develop policies for independent living residents, arrange training for relevant staff and ensure a copy of the Code is provided to all residents.
"This case is important and presents a valuable opportunity for the wider retirement village sector to learn from the events that transpired. The provision of health and disability services to residents who live independently within a retirement village setting is not unique to The Selwyn Foundation," Wall said.
"It is reasonable to assume that such living arrangements will only increase and become more complex in the future as the population of older people grows, and more demand is placed upon aged residential care services."
Wall said an increasing number of elderly people with comorbidities will continue to live independently in retirement homes and for these residents to remain safe roles and scope of responsibility of all parties involved need to be defined clearly and followed.
Since these events The Selwyn Foundation has made multiple changes to its procedures and processes and undertaken further training for its independent living Residential Services staff.
It has also reviewed and updated its standard occupation licence and disclosure statement for the retirement village, and updated its marketing material for independent living residents so the services they offer are described clearly, the HDC said.
