A woman in her 20s living with quadriplegia and unable to talk suffered "extensive blister burns" from urine after a nurse neglected her care for 12 hours.
A report, released today, reveals Christchurch-based community care home, St John of God Hauora Trust (SJOG), and the nurse were in breach of the Code of Health and Disability Services Consumers' Rights for the failure.
The code is a regulation under the Health and Disability Commissioner Act that health providers must comply with. Any New Zealander who feels their treatment, or lack of, did not follow that regulation has the right to complain to the HDC.
As a result of the investigation, Deputy Health and Disability Commissioner Rose Wall ordered the Nursing Council of New Zealand to review the nurse's competence and the assisted living facility to audit its care and review its processes.
However, the decision comes nearly two years after the accident and the woman's mum says her daughter is still facing ongoing problems with her skin where the burns were sustained.
Mrs B (the mum) told the HDC that her main concern was not so much about how the burns came about, but rather how her daughter was left to suffer for so long.
Names have not been used in the report due to privacy reasons.
While under SJOG care in 2019, the woman's continence product leaked and left severe urine burns to both thighs, the report said.
The investigation found there was a 12-hour delay to monitor and replace the continence product and that it was not in the right position and was too large.
It also found there was also a lack of frequent pain assessments, inadequate medication administration, inconsistent documentation, a failure to seek a timely medical review, and insufficient communication with the woman's welfare guardian.
SJOG told HDC: "A great deal of reflection has taken place by all staff involved in this event.
Staff have been very concerned that due to a lapse in ensuring best practice, [the woman] received an injury which resulted in a decision being made to move her to another facility."
The Deputy Commissioner criticised SJOG, saying they failed to provide services with reasonable care and skill, and in a manner that respected the woman's dignity.