Rest home staff who left an elderly woman's broken hip untreated for several days have been ordered to apologise and will be reviewed by the Nursing Council.
The Health and Disability Commission said the 81-year-old woman with advanced dementia went into a secure dementia unit at the Killarney Rest Home in Tauranga in 2011 for respite care.
A report by the deputy commissioner said there was no evidence of a care plan or adequate assessment on admission and the woman fell three days after her arrival, bruised her forehead and became unresponsive.
She went to hospital and was discharged back to the home four days later, then requiring fulltime care.
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She sustained other falls over the next month, which were not always reported to family. She reported a painful left leg and was unable to stand, but there was no record of her being assessed or her pain or mobility being managed.
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.