Auckland retirement village failed resident who died after fall - report

An Auckland retirement village has been found to have failed to provide adequate services to an elderly resident whose fall later resulted in her death.

Deputy Health and Disability Commissioner Rose Wall today released a report finding Aria Park Senior Living Limited in breach of the Code of Health and Disability Services Consumers’ Rights by failing to provide reasonable care and skill after the fall. 

The woman experienced an unwitnessed fall, which resulted in leg and arm pain, and she was unable to stand or weight bear independently, Ms Wall said in a statement.

The next day, there were difficulties moving the woman with a transfer belt. Her pain escalated, and she was reviewed by a GP who recommended that she be taken to hospital for further investigation, authorities said. 

At the hospital, it was found the woman had an elbow fracture, so she was transferred back to the retirement village with instructions to continue her regular pain relief. However, this did not occur and the woman was re-hospitalised due to increased pain levels and later died, the agency said in a statement.

Ms Wall’s investigation found failures with respect to the retirement village’s pain assessment and administration, incident reporting, documentation, compliance with its manual handling policy and communication. There were also delays in obtaining a GP review and in contacting an ambulance, investigators found. 

Ms Wall said in her report there were serious issues with the care the woman received from multiple staff members at the retirement village and that the care was inadequate.

She found that the retirement village "had the ultimate responsibility to ensure the woman received care that was of an appropriate standard and complied with the code".

Ms Wall recommended that the retirement village report back to the health and disability commissioner on a number of issues, including further education it provided to staff and improvements to its services in the areas of medication administration documentation; the process to support the use of restraint and restraint use documentation; incident reporting; and the process of seeking medical attention and transferring a resident’s care to a hospital.

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