A rest home has been found in breach of the health code after an elderly woman died of an infection resulting from bedsores.

Deputy Health and Disability Commissioner Rose Wall today released a report finding the rest home and a registered nurse in breach of the Code of Health and Disability Services Consumers' Rights over the woman's care.

The woman, in her 80s, was admitted for respite care in 2014 to a rest home contracted by an unnamed DHB.

She developed blisters on her heels and a skin tear and pressure sore over her sacrum at the base of her spine. Over the following three months the wounds were assessed regularly and the conditions described on wound care plans by various rest home staff.

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Descriptions of the sacral wound were sometimes incorrect and contradicted each other over how well the wound was healing.

There is also dispute over how many times the clinical and nurse manager tried to contact the regional wound care specialist for advice.

The specialist never physically reviewed the woman's wounds, and although local GPs did check on the woman a GP never looked at the sacral wound until months later.

One day in 2015, nursing staff noted the woman was unwell, with rapid breathing, high blood pressure, temperature and heart rate. She was rushed to hospital and treated for suspected sepsis with antibiotics. Although she initially showed signs of recovery, she died a few days later.

A GP stated at the time that the woman's heel and sacral wounds were likely to be the cause of her acute deterioration.

The report comes as a Herald investigation reveals a litany of problems at rest homes around the country, including at least two other deaths attributable to bedsores.

Descriptions of the woman's sacral wounds were inaccurate and inconsistent depending on the staff making them. The company's wound-care policy and form made this worse, the deputy commissioner found.

Rest home staff did not give GPs the full and accurate information they needed to make decisions, Wall said in her decision, released today.

She found the rest home failed to provide services to the woman with reasonable care and skill.

Wall also considered that the clinical and nurse manager, as the person with clinical oversight of staff, did not provide services with reasonable care and skill.

The deputy commissioner recommended the rest home arrange training for its staff on wound care, effective communication with family members, GPs and other clinical personnel and clinical documentation skills.

The rest home and the clinical and nurse manager each provided a written apology.

HERALD INSIGHTS: Is your local rest home up to standard?