A rest home has been found to have failed an elderly man with dementia after staff did not notice he lost 12 kilograms in seven months before his death.
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In a report, Deputy Health and Disability Commissioner Rose Wall found the CHT Healthcare Trust rest home did not provide the fundamentals of care to the man, who was in his 90s, in the last 10 months of his life.
His weight was recorded at 71.7 kilograms when his condition began deteriorating. When weighed seven months later, he had lost 12.3kgs. It was around this time he was also diagnosed as likely having bowel cancer.
Staff then intervened and the man gained 2.7kgs in the two months before his death.
The failure to manage his weight loss, undertake nutritional care planning and monitor his food and fluid intake meant staff did not recognise his condition was deteriorating before his death.
It also found there was a lack of engagement with the man's daughter, who held his enduring power of attorney. She was not made aware of her father's altering state of health, including his blood test results, and was not given the opportunity to participate in decisions relating to her father's care.
Wall said despite receiving two-yearly training, the nurses involved in the man's care failed to think critically and adhere to the internal policies in place at the rest home.
"In my view, it is the responsibility of the rest home to ensure that its staff are aware of their obligations and are providing services consistent with accepted practice.
"While I am concerned about the lack of oversight of the man's care plans, I am also of the view that it is the responsibility of all staff involved in a resident's day-to-day care to be observant and alert to subtle, or not so subtle, signs of deterioration in the resident's general condition, and be ready to escalate matters of concern."
The man's daughter told the Health and Disability Commission that her father's deterioration in the last eight months of his life was significant, and she felt the lack of action and basic care provided to him may have been a contributing factor in his death.
Wall recommended the rest home provide a written apology to the man's family, undertake an audit to confirm a weight loss procedure was being followed and provide nursing staff with training on care planning, weight loss monitoring, and food and fluid intake.
CHT Healthcare Trust operates 16 rest homes across Auckland, Waikato and the Bay of Plenty.
Chief executive Carriann Hall said it acknowledged the findings of the HDC report and took any complaint regarding the care of its residents very seriously.
"We have reached out to the family involved with our sincere apologies and acknowledging the distress this experience caused them.
"We have made improvements to the everyday care of our residents based on the recommendations within the report, including strengthening our processes around the identification and management of weight loss and improvements to training for our staff."