Several days later the woman was reviewed by the clinical manager and found to be in severe pain. An x-ray revealed she had a fractured hip and she was taken to hospital. She did not return to the home.
The Health and Disability Commission found several failings on the part of the clinical manager, a registered nurse, including failing to make a care plan or inform the woman's family of her falls.
The clinical manager, rest home manager, who is an enrolled nurse, and rest home operator were found to have breached the code of rights by failing to provide services with reasonable care and skill.
They were ordered to apologise to the woman and her family, and the two nurses were referred to the Nursing Council for competence review.
Another newly qualified registered nurse was found to have contributed to the poor quality of care, but no action was taken.
Killarney Rest Home has since been sold and is now under new management.