The Deputy Health and Disability Commissioner (HDC) has found a patient died after choking to death on a sausage when a support worker left her shift early.
IDEA Services and a support worker have been found in breach of the Code of Health and Disability Services Consumers' Rights in their care of a resident.
In a report released on Monday, HDC said a patient had died after choking to death - a death that was preventable given staff didn't follow the man's support plans.
Instructions for the man's support plans included ensuring his food was cut into manageable-sized pieces and being present with him when he was eating.
Staff were also meant to give him verbal prompts to chew his food properly before swallowing.
Deputy Health and Disability Commissioner Rose Wall found IDEA Services breached the right to reasonable care and skill and the right to services provided in a way that minimises harm and optimises quality of life.
"IDEA Services failed in its duty to manage the resident's risks, keep him safe and provide an appropriate standard of care," Wall said.
A support worker was also found to have breached the right after leaving her shift early before the man's meal was served.
An internal investigation concluded the key factors contributing to the man's death were his food was not cut up and the house being short-staffed due to the other staff member leaving early that day.
It also noted the support worker who found the resident unresponsive failed to first clear the man's airway before applying CPR.
According to Wall, IDEA Services did not comply with its own significant hazards register or have a consistent and unambiguous support plan for the man.
She noted IDEA Services' failure to make sure its staff adhered to the man's support plans, ensure staff training was up-to-date and have adequate staffing levels.
"By not adhering to the resident’s support plan to mitigate his risk of choking, and not attempting to clear his throat before commencing CPR, [the support worker] did not provide services to the resident with reasonable care and skill," she said.
Since the death, IDEA Services has formally apologised to the man's family and reminded staff of the importance of adhering to individual support plans.
According to HDC, it has also revised its safer eating and drinking programme and reviewed its first aid training records to make sure its staff training is up-to-date.
