A rest home has been criticised for failing to provide the level of care required for a 90-year-old woman who had surgery and later died while suffering pneumonia and overwhelming inflammation.
A public hospital had discharged the woman back to her rest home following the skin cancer surgery on her lower left leg in 2012.
It recommended that she be cared for in the home's hospital wing, where a higher level of care was provided than in the rest home wing, according to a report issued today by deputy health and disability commissioner Rose Wall.
The facility, which was not named in the report, had no beds available in its hospital wing so put the resident back into its rest home area.
Ms Wall said that despite the lack of a hospital bed for the woman, the facility should have ensured that adequate staff were available to monitor her and to provide the level of care that she required.
After the rest home took over management of the woman's surgical wound from the hospital's outpatients' clinic, the wound deteriorated and MRSA (methicillin-resistant staphylococcus aureus) was diagnosed and treated with an antibiotic.
The state of the wound worsened and the woman was twice found in a confused and disoriented state.
Following the second of these occasions she was taken back to the public hospital, where she was found to be suffering from pneumonia and "overwhelming sepsis", an potentially fatal inflammatory reaction to infection. This illness was reported as not related to the earlier MRSA.
Active treatment was withdrawn and she died three days later, which was around 10 weeks after the skin cancer surgery.
Ms Wall said the rest home and two senior nurses had breached the code of patients' rights. The rest home and one nurse had failed to ensure the woman received proper clinical care and the other nurse personally failed to provide services with reasonable care and skill.
A new care plan was not implemented when the woman returned to the rest home, information was not given to her or her daughter, and there were concerns about the adequacy of staff responses to the woman's deteriorating condition, including when she was found to be confused and distressed.
Ms Wall also criticised the rest home's documentation.
"In this case the rest home had no systematic approach to documentation, which caused staff to have an incomplete picture of the woman's condition, and staff consistently failed to document the woman's care and treatment adequately."
The rest home and both nurses have apologised to the woman's family. Ms Wall recommended that the home consolidate its documentation system, train its staff and audit its compliance with professional standards on documentation.