A rest home nurse manager faces disciplinary action after an 86-year-old woman rapidly lost weight and was often left in soiled clothing, a Health and Disability Commission report says.

Willows Rest Home Ltd in South Auckland was found to have breached several health and disability services consumers' rights, according to the HDC report.

The woman, named Mrs A, was not provided service with reasonable care or skill, according to deputy health and disability commissioner Theo Baker.

"The failure by a number of registered nurses to monitor and assess Mrs A appropriately, and document adequately, demonstrates a lack of clinical leadership or insight by [the nurse manager], " she said.


Mrs A's daughter told HDC she did not think her mother was being fed enough and when she spoke to a nurse about it, she was told it did not matter if Mrs A did not eat, so long as she had fluids.

She said her mother often did not have socks on her feet in winter, and was often fully clothed in bed and drenched in urine or soiled when she visited her.

She also criticised the deterioration in her mother's mobility and, in one instance, the home's failure to inform the family of changes in her mother's condition.

The report found that Mrs A had had a number of changes to her condition, including a suspected mini-stroke, a number of falls, swallowing difficulties and rapid weight loss during her time at the home.

"Leaving Mrs A for an unreasonable length of time soiled or wet from urine could have compromised her health, and showed a lack of respect for Mrs A's dignity," Ms Baker said.

Ms Baker said the home's care plan had not recorded how to manage Mrs A's diabetes, dietary needs, prolapses, dementia and swallowing difficulties, and it was not updated when required.

Ms Baker was critical of the fact the home did not provide a clear indication of how much food Mrs A was eating, despite her rapid weight loss and type 2 diabetes.

Mrs A was eventually transferred to another rest home at the request of her daughters, and was admitted to hospital after approximately a week. She died four days later.

The report will be sent to the Nursing Council of New Zealand who will be advised of the nurse manager's name, and to the District Health Board, the New Zealand Aged Care Association, and the Ministry of Health.

HDC recommendations included:

* provide an update on staff compliance with its policies and procedures;

* provide an update on its monthly care planning and registered nurse communication book audits implemented since these events, including the results of the last audit for each undertaken;

* introduce a separate weight chart/graph for each resident;

* conduct staff training on the appropriate use of bowel charts, and conduct an audit of its bowel charts; and

* provide HDC with an update on these matters by 11 July 2014.