A retirement village has apologised for not providing a 95-year-old woman with adequate care in the months leading up to her death.
The apology came after a ruling by the Deputy Health and Disability Commissioner on a complaint from the woman's daughter.
Mrs A weighed 38.6 kilograms a month after being admitted to Fairview Care, a retirement village and hospital in Albany in Auckland's north, the ruling said.
She had a history of breathing difficulties and weight loss and needed a pureed diet.
There was no short-term care plan completed and no long-term care plan until she had been at Fairview for nine months. By then Mrs A's weight had increased to just under 40kgs.
A month later she was found to be dehydrated and staff were advised to push liquids and start a fluid balance chart. A doctor found her to be underweight and recommended supplements but she continued to lose weight.
By month 15 in Fairview Care, Mrs A weighed just 35.55kgs and though staff observed her reluctance to eat, nothing was done to investigate the problem, the ruling said.
An updated care plan failed to refer to her pureed diet and her ongoing weight loss among other factors.
Soon after, Mrs A had an unwitnessed fall but did not sustain any injuries. She was found on the floor next to the toilet by a healthcare assistant.
A doctor's appointment was cancelled during month 16 as the doctor ran out of time, and after this Mrs A's condition deteriorated and she was taken to public hospital.
She had pneumonia and was discharged to another private hospital a month later. She died three weeks later.
The conditions around her death formed the basis of a complaint to the Deputy Health and Disability Commissioner laid by Mrs A's daughter who questioned whether an adequate standard of care was provided between her second and 16th month at Fairview.
Fairview Care said in response that Mrs A was a very independent woman who increasingly expressed a desire not to eat. She refused assistance and staff also found food hidden in tissues.
Fairview disputed that her weight was not adequately monitored.
The retirement village's general manager said: "Given that this is most residents' final home you become aware of [residents'] lives drawing to a close and I personally felt this was so in [Mrs A's] case..."
Fairview Care accepted that its documentation might be open to criticism but insisted its staff were seriously concerned for Mrs A's weight loss.
The Deputy Health and Disability Commissioner Theo Baker found there were deficiencies in the care provided to Mrs A by Fairview Care, particularly in relation to care planning, weight management and the response to her weight loss, and the assessment and monitoring of her nutrition and hydration.
Among several recommendations, she asked Fairview Care to apologise to Mrs A's family and to undertake an audit of its care plans.
The deputy commissioner's report, published today, said Fairview Care had complied with these recommendations and provided a written apology.
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