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Staff at a Tokoroa rest home who failed to provide adequate respite care for an elderly man who died have been ordered to apologise to his family.
The man in his 80s had Parkinson's disease, heart failure and recurring strokes when he had an unwitnessed fall on his first day of a five-day stay at Victoria Place Rest Home, owned by Oceania Care Company.
Aged care commissioner Carolyn Cooper said Oceania Care Company breached the man's rights by not undertaking a risk assessment or responding properly to his fall.
On his first night at the rest home, the man had an unwitnessed fall and his condition began to deteriorate from there, Cooper said.
On the third day of his stay, the man's whānau insisted an ambulance be called and he was admitted to hospital where scans indicated he had suffered strokes.
The man's health continued to decline and he died two weeks later.
Cooper found after the man's fall, no post-fall assessment was done and he was not observed for any neurological issues.
The man was short of breath, Cooper said, but there was "minimal" follow-up monitoring of this by staff.
A "lack of respect" was shown to the man and his whānau, Cooper noted.
This included staff being dismissive of injuries post-fall, disregarding a letter from the man's GP that was shown to staff by his wife, and only calling an ambulance when his daughter-in-law threatened to drive him to hospital herself.
"Although some of these incidents are disputed, and, if they occurred, could be seen to be the actions of individual staff, my view is that management should set a positive culture with residents' wellbeing at the centre, and Oceania failed to do so," Cooper said.
A nurse at the home also breached the code for failing to provide services with reasonable care and skill.
Cooper said the nurse needed to "take responsibility for her failures" and the failures of several of her staff to provide appropriate care to the man.
Several recommendations were made for Oceania Care by Cooper which included apologising to the man's family.
Cooper noted Oceania Care had made several changes since the complaint.