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An elderly rest home resident dragged her left leg around for a week after her broken hip was missed by two nurses and the company that owned the care facility.
A Health and Disability Commissioner's report found medical professionals and the rest home company in breach of the Code of Health and Disability Services Consumers' Rights for failing to respond to the elderly woman's poor health.
The report revealed how staff failed to start a short-term care plan for the woman after they found a reddened area on her back.
A registered nurse applied a Duoderm dressing to her back wound but staff did not record the size of the wound or describe how serious it was.
The woman, who was a long-term resident at the unnamed centre and had osteoporosis, had two falls within three days while walking with her mobility frame.
The nurse manager completed an incident form after the first fall, and a follow-up was scheduled with a general practitioner.
After the second fall, the nurse manager examined the woman and instigated short-term and pain management care plans -- but gave few written instructions for staff to follow.
The nurse manager also did not advise the GP that the woman had fallen.
The report also showed the registered nurse covering during the nurse manager's 10-day leave did not review the woman's incident reports or handover sheets.
The registered nurse noted the woman had new bruising and her left leg was "dragging" but did not consider a fracture as the cause, seek advice from the GP or the hospital -- and did not advise the woman's family of the bruising.
A visiting physiotherapist examined the woman -- a week after her second fall -- and considered she had a recent hip fracture before she was transferred to hospital where she was diagnosed with a fractured neck of femur -- and treated for the pressure wound on her back.
Aged Care Association chief executive Martin Taylor said the 2012 incident highlighted a "breakdown in communication" between the staff entrusted with the woman's care.
"Handover processes are really important and they have to be done well and when someone goes on leave - which seems to be the genesis of this issue -- you have to be really focussed to make sure nothing is overlooked.
"In this case, sadly, it was overlooked."
Deputy health and disability commissioner Theo Baker said the informal nature of handover communications in the matter meant important clinical information wasn't passed on.
Ms Baker said the facility's owner/operator also did not ensure that appropriate systems, policies and guidelines were in place to provide services to the woman.
She recommended the nurse manager review her nursing practice and complete refresher education in aged care while the registered nurse review her practice in conjunction with the Nursing Council before renewing her practising certificate.
She also recommended that the rest home conduct a review of its systems and develop a clear and comprehensive set of updated and co-ordinated policies and procedures.