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The Health and Disability Commissioner has determined an Auckland retirement village breached code by failing to care for an unwell resident.
A woman in her 80's was found slumped in her chair at Selwyn Village, after previously refusing to see a nurse. She had been visited by a staff member, but could not remember what caused her fall.
The staff member left her, but later returned and found her in pain and unable to move. She was then swiftly taken to hospital.
Deputy Commissioner Rose Wall said the incident raised questions about the responsibilities retirement villages have for their residents.
The situation could have been avoided if Selwyn Village had established clear guidelines for such incidents, she said.
"This case is important, and presents a valuable opportunity for the wider retirement village sector to learn from the events that transpired," she said.
Wall said residents were treated inconsistently across the sector.
"For the system to operate effectively and for these residents to remain safe and continue to live well, it will require respective roles and the scope of responsibility of all the parties involved in provision of health services, to be defined clearly and followed consistently," she said.
Wall recommended that The Selwyn Foundation apologise to the woman's family, and warned the wider sector to take the incident as a warning.