A man under rest home care died from a heart attack after a nurse made no attempt to save him.
The Hokitika nurse has been found in breach of the Code of Health and Disability Services Consumers' Rights for failing to attempt resuscitation on a collapsed man, a decision released this afternoon revealed.
Deputy Health and Disability Commissioner Rose Wall said the decision not to do so could have saved his life.
In 2016 the nurse found the man "slumped between the toilet and the wall with his head touching the floor"of his Allen Bryant Rest Home bathroom.
When the man was admitted to the rest home earlier in the year he signed a consent form to say that if anything happened to him he wanted to be resuscitated.
But the nurse failed to do so.
Instead she called for assistance and, with the help of a caregiver moved the man so that he was lying on the floor.
She performed a brief "signs of life" assessment but she did not attempt to resuscitate the man.
The nurse directed the caregivers to attend other patients and left the man lying on the floor while she went to reception and rang an ambulance.
The ambulance officer told HDC that the man was still warm when she arrived and that she commenced CPR but was unsuccessful.
Wall said the nurse should have attempted to resuscitate the man.
The rest home was found liable for the actions of the registered nurse, as it had not taken reasonably practicable steps to prevent the conduct from occurring.
Wall made adverse comment about the lack of insight demonstrated by the rest home in its response to this complaint.
Wall decided to refer the registered nurse to the Director of Proceedings for the purpose of deciding whether proceedings should be taken.
She also recommended that the registered nurse provide a written apology to the family and undertake training in resuscitation.
The rest home was told to apologise to the family and review its policy and documentation regarding resuscitation.
General manager of Allen Bryant Clinical Carole Kaffen said the rest home had been working with HDC since the complaint was made in 2016.
"The commissioner has been satisfied with our work to prevent this from happening again.
"The Ultimate Care Group strives to provide the best quality of care," Kaffen said.