A rest home has been asked to apologise to the family of a paralysed elderly man who had dementia after he died six months after being admitted.
The rest home, owned by Oceania, had "serious issues" with the care planning and delivery of care to the man, a recent Health and Disability Commissioner decision concluded.
The man's son had complained to the commissioner about his care.
"The day [my father] was admitted there appeared to be limited information written down regarding his needs; the desire seemed to be to tick off boxes on a form and unfortunately [he] did not fit into any of their boxes."
The man, in his 80s, was paralysed from an accident 26 years earlier, had frontal lobe dementia and chronically low pressure.
He also had a catheter and a colostomy.
Before he was admitted to the rest home, his wife had cared for him.
"The rest home accepted Mr A into its care and, as such, it then assumed responsibility for meeting his needs and keeping him safe," Wall said.
"Without the appropriate support and interventions, Mr A’s health had the potential to deteriorate rapidly, and he was at risk of developing complications."
During his time at the rest home, the man developed pressure wounds on his heels and buttocks because he was restrained in a reclining chair when he was not supposed to be.
Use of the chair was apparently not phased out but stopped because the man required bed rest for his pressure sores.
The rest home made the decision against Oceania's policies after he tried to leave the rest home.
His family only gave consent for the use of restraint on the man on the understanding pressure relief would be provided.
The man was meant to be observed and monitored at least every hour, but Deputy Commissioner Rose Wall noted this did not seem to be the case, according to the man's family.
The man also developed a urinary tract infection, which he was admitted to hospital for.
Wall's decision noted his catheter was partially blocked.
He was later admitted to hospital again with pneumonia, an increased heart rate, fluid on his lungs, another UTI and another pressure wound.
While in hospital, his family arranged for him to be discharged to a different rest home.
He died shortly afterwards, Wall said.
"The most alarming thing about [the rest home] was their assurance that they knew how to care for a patient like [my father] whereas clearly they did not," the man's son said.
A total of eight registered nurses, one enrolled nurse and 23 healthcare assistants were involved in the man's care.
Oceania told the HDC it felt staff at the rest home did not have skills to provide the expected quality of care to the man, who had a complex medical history.
It said it should have been consulted over whether or not to admit the man in the first place - it felt he should not have been.
Wall's recommendations included the rest home arranging training on pressure area risk assessment and management, reviewing its restraint policy and providing evidence staff were aware of the statutory obligations for reporting pressure areas.