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An elderly woman living at an aged care facility was given the incorrect dose of blood thinners six times, by six different nurses, over a five-month period.
On Monday, Deputy Health and Disability Commissioner Rose Wall found Sunrise Healthcare Limited (trading as West Harbour Gardens) in breach of the Code of Health and Disability Services Consumers' Rights for failures in its care of the woman, referred to as Mrs A.
In 2015, Mrs A, aged in her 90s, was admitted to West Harbour Gardens residential care facility in west Auckland. She required hospital level care.
Mrs A had a heart condition, for which she was prescribed warfarin (blood thinners).
Over a five-month period between July and November 2018, six nurses at West Harbour Gardens gave Mrs A the incorrect dose of warfarin.
There were six occasions when 3mg of warfarin was administered instead of the 2mg charted.
On a separate occasion, the administration and documentation of the medication was left incomplete.
The medication errors were not identified until a year after they occurred, when West Harbour Gardens was responding to complaints made by Mrs A's family about her general care while at the facility.
There was no evidence the care facility ever undertook a formal investigation into the matter and told the HDC it could not locate the incident report.
Mrs A's daughter said the family was not informed of the errors.
Wall said "systemic failures" at West Harbour Gardens had led to Mrs A receiving the incorrect dose of medication on multiple occasions.
"I cannot over-emphasise the potentially serious consequence of the woman not receiving her prescribed dosage of warfarin."
She was critical the facility's policies and procedures did not include open disclosure with Mrs A's family.
"When the errors were identified, they were not documented in an incident report form, no investigation report was completed and corrective actions were not documented formally.
"As such, the opportunity to identify the cause of the medication errors and implement remedial actions in a timely manner was lost," she said.
Wall recommended Sunrise Healthcare provide Mrs A and her family a formal written apology.
She also recommended Sunrise Healthcare audit any medication errors at West Harbour Gardens over a three-month period and review its critical incident reporting policy.
Since the incidents involving Mrs A were identified, West Harbour Gardens had made a number of changes to ensure medication was administered correctly, Wall said.
The facility has been contacted for comment.