An 81-year-old woman with advanced dementia living in a rest home was left for five days in pain with a fractured hip before she was sent to hospital.
The woman went to Killarney Rest Home in Tauranga in July 2011 for respite care. A week later she was admitted for long-term care, after a fall in which her forehead was bruised, and she was noted to be unresponsive, deputy health and disability commissioner (HDC) Rose Wall said in a decision.
In the next few weeks the woman had another fall and also received a blow to her head from a door swinging back onto her.
Shortly after 11pm on August 3 she fell again, reporting a painful upper thigh.
The clinical manager, a registered nurse, assessed the woman's left hip area but found no injury.
On August 6, the woman's daughter found her mother incoherent, and her whole leg down to the ankle "very bruised, swollen, and cold", the decision said.
On August 9, the clinical manager noted the woman was in a lot of pain and unable to take weight on her left leg or to walk.
"On my return (following four days' leave) I was horrified to find that (the woman) was very distressed and in pain and she had not been seen to," the clinical manager told HDC.
The woman was sent to hospital where an X-ray showed a fracture to her thigh, and she had surgery the next day.
The woman's family had been unwilling for her to return to Killarney and she went to another rest home.
"In my view, the care provided to (the woman) was very poor," deputy commissioner Wall said.
"Of particular concern is the fact that she was left from Wednesday, 3 August 2011 until Monday, 8 August 2011 with a fractured hip and in considerable pain."
Wall found the clinical manager, rest home manager, and owner and operator of Killarney Rest Home (Killarney Rest Home (2009) Ltd) all had responsibility for the poor care the woman received, and breached the Code of Health and Disability Services Consumers' Rights.
In particular, they failed to ensure the woman had complete admission documentation, including a care plan and appropriate assessments such as a falls risk assessment, and failed to keep the woman's attorney and family informed of her falls.
Furthermore, the clinical manager and rest home manager failed to seek a GP review of the woman after her third fall.
Killarney Rest Home (2009) Ltd failed to provide safe care to the woman, and ensure its staff were complying with its policies and procedures, and failed to ascertain the woman's legal status or respond appropriately following her falls.
Killarney Rest Home had since been sold and was under new management, the decision said.
The rest home, the clinical manager, and the manager were referred to the director of proceedings to decide whether proceedings should be taken. The director had yet to make a decision.
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