An elderly man died from injuries inflicted when a fellow rest home resident assaulted him.

A Health and Disability Services report released today found a Napier rest home in breach of the Health and Disability Services Consumers' Rights Code over the incident which saw an 87-year-old man die.

At the time of the event, the man was a resident in the dementia unit of the Anglican Care Waiapu rest home.

In late 2015, he was physically assaulted by another resident in the dementia unit after he went wandering at approximately 4am.

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The report said the other resident was seen kicking the victim in the abdomen while he was on the floor.

He was found to have a large bruise on his forehead, a skin tear on his left wrist and a small tear on the right elbow, as well as complaining of back pain.

A Health and Disability Commissioner report released today found that Anglican Care Waiapu had failed to manage the man's wandering and provide adequate care following an assault.

Nursing notes had documented the man's regular wandering behaviour, which included going into other residents' rooms.

Despite this behaviour, no behaviour management plan was completed for the man.

The rest home told the Health and Disability Commissioner that following the assault, the man's overall clinical management was not facilitated by a designated senior nurse or clinical manager.

No short-term care plans were commenced for the man's ongoing essential care, and, despite him being checked a number of times by staff on the morning, evening, and night shifts on the day of the assault, he was not referred to a general practitioner.

The man was checked by a registered nurse the day following the assault.

The registered nurse documented that the man found it painful to stand, and asked the team leader in the dementia unit to seek medical advice.

Later that morning, the man was reviewed by the duty doctor, who arranged for the man to go to hospital for X-rays.

The man returned from hospital having been diagnosed with multiple rib fractures and fluid in his right chest.

The man's next of kin did not want him to be given a chest drain or intubation, so he received comfort care. The man passed away a short time later.

Deputy Health and Disability Commissioner Rose Wall considered that the failure to manage the man's wandering behaviour appropriately, and the overall deficiencies in nursing care after the assault, demonstrated a pattern of suboptimal care and a lack of critical thinking from numerous staff members.

Wall considered the shortcomings to be service delivery failures, directly attributable to the rest home, and therefore that the rest home failed to provide services to the man with reasonable care and skill.

She recommended that the rest home consider whether any of the learnings from this investigation can be translated into improvements throughout its other aged care services.

Anglican Care Waiapu delivers a range of services throughout the Bay of Plenty, Hawke's Bay and Eastland regions, including; early childhood education, family services, youth mentoring, grief services and day centres for the elderly.