Ranfurly Manor in Fielding. Photo: Google Maps
The Health and Disability Commission has found a Fielding retirement village left a resident's broken ankle untreated for nine days.
The elderly woman was put in an electric wheelchair at Ranfurly Manor on 7 November 2020, despite her care plan saying "[The woman] will ask the staff to set her up in her electric wheelchair but is unable to use this as she poses a safety risk to herself and others due to frequent mishaps".
She then slid out out of the wheelchair and was found on the floor by a carer.
While no initial injuries were found, the woman complained of pain in her lower legs in the days following.
It took nine days before a GP referral happened on 16 November, and an x-ray showed the woman had broken her ankle in the fall.
Ranfurly Manor staff had documented 20 complaints in that time - on six occasions, the pain was significant enough for the woman to be given morphine.
"This raises concerns about staff adherence to care plans and the manner in which important information about residents' care [was] communicated between staff," Aged Care Commissioner Carolyn Cooper said.
The policies in place at Ranfurly Manor to guide resident care at the time were sound, she said.
"However, the fact that multiple staff did not follow them consistently meant that service delivery was sub-optimal."
Ranfurly Manor had since made several changes, which included moving to an electronic resident monitoring programme and conducting a daily review of adverse events and handover notes for registered nurses, team leaders and the clinical manager.
Cooper recommended the retirement village provide an example of the changes including random audits of staff compliance and an audit of pain management monitoring.
It was also recommended Ranfurly Manor provided an update on changes to how family members were told about adverse events and write an apology to the woman's family.
Cooper said sadly, the woman passed away during the course of the investigation, and offered her condolences to the whānau for the loss of their loved one.