An elderly woman died less than 24 hours after arriving at a rest home, having not been given her regular medications.
And four nurses involved in her care have been criticised by the deputy Health and Disability Commissioner.
This comes three years after a complaint was made to the Health and Disability Commission (HDC) after the woman died shortly after being admitted to a rest home operated by Oceania Care Company Ltd.
It was found that the woman, who had diabetes, did not receive her regular medication, most notably insulin, and died 24 hours after she first arrived at the facility.
The HDC found two nurses and the Oceania rest home itself had breached the code of Health and Disability Services Consumers’ Rights for failing to provide the woman with reasonable care and skills.
Two other nurses were also mentioned in the ruling.
"The care provided to the woman fell short of acceptable standards in a number of areas in a time frame of less than 24 hours,” said HDC Deputy Commissioner Rose Wall.
"At least three of the four nurses involved in her care failed to fulfil their clinical responsibilities and adhere to policies and procedures.
"People in an aged residential care setting frequently present with multiple comorbidities and complex health conditions, and often are not in a position to advocate for themselves or alert others to issues of concern,
"It was reasonable to assume that all those health professionals involved in this woman’s brief episode of care should have been competent to recognise and manage her conditions,” she said.
Oceania has policies in place to ensure that all medication for new admissions are properly managed.
On the woman's admission assessment it was made clear that she was receiving warfarin and insulin however she did not receive the potentially life-saving medications when she needed them.
"Despite that notice, and having policies and procedures to manage this exact situation, the woman did not receive a prescription or verbal order for life-saving medications and, tragically, did not receive medications that could have managed her blood-sugar levels and ultimately prevented her death,” Rose wall said.
"While there is individual accountability, Oceania must take responsibility for failures at an organisational level.”
The HDC has recommended that Oceania review its guidance and policies for staff and suggested follow-ups to GPs where urgent medical review is requested.
It has also used this case as an example highlighting the importance of forward planning for new admissions.
Wall has suggested that Oceania and the four nurses involved write apology letters to the woman's family.
She also recommended the Nursing Council consider whether two of the nurses should have their competence reviewed.
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