An elderly man who was paralysed with dementia died after a rest home failed to provide appropriate support and interventions.
Oceania Care has been found in breach of the Code of Health and Disability Services Consumers' Rights for multiple failures in the man's care.
"The most alarming thing about [the rest home] was their assurance that they knew how to care for a patient like [my father] whereas clearly they did not," the man's daughter said in the Health and Disability Commission (HDC) report released today.
She said when things started to go wrong and her mum tried to talk to them about the problems, she wasn't listened to.
"There was clearly a lack of interest in trying to talk to her … There seemed to be limited information across the whole site and things appeared poorly run."
The investigation findings come about three years after the man's death. Names have not been published in the report for privacy reasons.
While the man lived at the rest home, he developed serious pressure wounds and was hospitalised for urinary tract infections (UTIs).
Deputy Health and Disability Commissioner Rose Wall suggested these hospitalisations could have been avoided and that he may not have deteriorated so rapidly had effective actions been taken.
She said clinical assessments, documentation and plans to mitigate the risk of his injuries were inadequate.
Wall recommended that Oceania arrange training on resident care planning and pressure area risk assessment and management.
The deputy commissioner also ordered an audit of long-term person-centred care plans and monitoring forms.
Facility staff were also told to apologise to the man's family.