When Mr A arrived at Radius St Winifred's his wife had provided a letter explaining the wounds on his leg and how they needed to be dressed.
The Deputy Commissioner's report identified that Mr A's wounds were dressed by different nurses during his stay but there was no consistency in how the nurses were assessing the state of his wounds.
When Mr A was discharged from Radius St Winifred's he returned to his home with his wife and son. His wife found his toe bleeding through his sock. She was shocked at how his wounds had deteriorated and she took him to his GP.
He was taken to hospital and his leg was amputated below the knee.
The Deputy Commissioner's report identified a number of failures in the care provided to the man by Radius St Winifred's.
In particular, Ms Baker was concerned about deficiencies in care planning, management of the man's wounds, documentation, and communication between staff.
The facility was found to have breached the Code of Health and Disability Services Consumers' Rights for those failures.
Ms Baker's report identified that the man's wounds were not managed adequately by the nursing staff.
Ms Baker was of the view that a significant failing was that there was no oversight of the man's wounds by one registered nurse.
Six registered nurses, four enrolled nurses, and a number of healthcare assistants provided care to the man during his 18-day admission.
The Deputy Commissioner considered that this affected the ability of the nursing staff to identify changes to the wound status and, as a result, there was no continuity with the dressing changes and the reviews undertaken.
Ms Baker was concerned that many of the shortcomings were common to a number of staff, indicating systemic problems at the facility.
She made several recommendations including that Radius St Winifred's audit its wound care documentation, and provide training for registered and enrolled nurses on topics such as documentation, wound care, care planning, admission assessments and communication.
The facility was referred to the Director of Proceedings for consideration of further proceedings.
Radius Care managing director Brien Cree said the incident was a real tragedy and it took the situation very seriously.
The company's own investigation of the incident had found the man had been cared for at home by his wife, when he should have been in a public hospital, Mr Cree said.
The man had come to St Winifred's for two weeks of respite care so his wife could take a break.
Mr Cree said the facility did not offer critical care for patients, and that level of care could only be provided by a district health board (DHB) public hospital.
"Why he was not in a public hospital is unclear. The fact that the gentleman needed to be in hospital is something that should have been picked up on by the doctors and community care nurses that were caring for him as part of his home-care programme."
However, Mr Cree also accepted staff at St Winifred's did "miss some signs that this gentleman needed to be hospitalised".
"This gentleman presented with severe medical complications, had previously lost a leg to diabetes and we should have picked up that it wasn't respite care that he needed, it was hospitalisation at the DHB hospital level, and we did fail him in that regard -- for that oversight I'm truly sorry," he said.
"Since the incident, we have put procedures in place to ensure staff check more thoroughly on a patient that has come to us for respite care, even if they have been briefed that the client does not require hospital-level care, as we had been briefed in this case.
"While we continue to improve our processes, I would certainly hope that the DHB hospital and medical staff involved with this patient before he came to us will be examining how they could have let him be cared for at home by his wife, when he clearly needed hospital treatment."
