The Aged Care Commissioner has found a retirement home and two nurses failed to properly look after an elderly woman after a fall and her care records were falsified.
Carolyn Cooper said that the woman had an unwitnessed fall at Tamahere Eventide Home and Retirement Village on the outskirts of Hamilton.
The woman fractured her hip and shoulder and was admitted to hospital but died.
She said that the resident's care plan did not provide adequate support to manage her falls risk.
CCTV footage also showed the woman's personal care needs were not met in a timely manner, despite an hourly checklist being ticked by carers to indicate this had been done.
Cooper said together these, "demonstrate a pattern of suboptimal care and service failures at Tamahere".
She said that although it was the carers responsibility to undertake hourly checks, they worked under the direction of registered nurses and the rest home should have had adequate systems in place to ensure the resident checks were being carried out.
Neither of the nurses who attended had done a thorough assessment of the woman after her fall.
Cooper said the enrolled nurse on night duty should have escalated the fall to the registered nurse so a thorough assessment could be undertaken before moving the woman.
She also said it was the registered nurse's responsibility to undertake that assessment and to direct staff to ensure the injured woman received appropriate care.
"I am critical that a thorough assessment was not completed by either nurse who attended, and that the resident was assisted off the floor and required to walk to the bathroom when a fracture of her arm was suspected," Cooper said.
The registered nurse did not inform the woman's son until six and a half hours after the fall.
He was told that it was "nothing to worry about".
He was shocked to hear that the injury that he thought was minor, was in fact life-threatening.
Cooper recommended Tamahere review the training provided to staff in relation to falls management and that the nurses apologise to the family.