Elderly patient left lying in urine-soaked bed at Auckland retirement facility

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An 84-year-old man was found distressed in a wet bed after a rest home worker did not fill out a handover to let their colleagues know he was there.

An elderly patient with a leaking catheter was left in a urine-soaked bed at a north Auckland retirement facility because staff were unaware he was there.

In a report released on Tuesday, deputy Health and Disability Commissioner Rose Wall found the facility and two of its registered nurses breached the standard of care to which the patient was entitled.

The 84-year-old patient, identified in Wall's report as Mr A, lived at an independent town house at Evelyn Page Retirement Village in Orewa. The village is owned by Ryman Healthcare.

Mr A had suffered a leg fracture shortly before the April 2016 incident, and had been discharged to the town house after a hospital stay.

He and his wife struggled to cope at home following his injury, and he was transferred to a serviced apartment building, which was connected to the rest home at the facility, for a short stay, Wall's report said.

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The man was a resident at Evelyn Page Retirement Village in north Auckland's Orewa, but was transferred to a building connected to its rest home facility after he broke his leg.

He was unable to be admitted to the rest home itself, as it was full.

On the morning of Mr A's second day in the apartment, staff noticed his catheter was leaking.

A registered nurse told Mr A he would have to go to hospital to have a new catheter inserted, as village staff were unable to do it for him.

Due to a communication error, it was believed Mr A went to the hospital with his son that day to get a new catheter inserted. However, this did not occur.

At 10.30pm, the senior caregiver went off duty without updating the handover sheet and alerting the rest of the team that Mr A was in the serviced apartment.

Mr A's father, identified in the report as Mr B, arrived at the apartment about 11am the next day.

"An exchange occurred between Mr B and the senior caregiver in charge where it became clear that the caregiver was unaware that Mr A was still present in the serviced apartment," Wall's report said.

"The caregiver and Mr B went to the serviced apartment, where they found Mr A in a distressed state."

The report said Mr A's bed was wet and he had removed his catheter bag. He had not had breakfast or received any care from staff since the previous night.

His son told Wall he found his father "in a state of shock; cold, confused, dehydrated and in pain".

An ambulance was called, at Mr B's request, and Mr A was admitted to hospital.

Wall's report found the retirement village did not have adequate policies and procedures in place to provide short-term care for independent residents.

It failed to guide its staff to deliver the service in an appropriate and safe way, she said. 

Wall also found two registered nurses involved with Mr A's care did not provide him services with reasonable care and skill.

Wall recommended that the village give more training to the registered nurses and make changes to some of its policies and procedures.

She also recommended the two registered nurses provide a written letter of apology to Mr A's family.

Ryman Healthcare chief executive Gordon MacLeod said on Monday the company accepted Wall's findings and had apologised.

"We deeply regret that our care for our resident fell below our usual standards on this occasion, and we acknowledge the distress it caused," he said.

"The two staff members involved have also acknowledged the part they played in this failure, and have apologised to the family. They have also undertaken additional training."

Staff had "the best of intentions" in offering help to Mr A, but a series of miscommunications "ultimately led to a failure in his care", MacLeod said.

The company had put systems in place to ensure a similar incident did not occur again, he said.

"When things go wrong we are determined to learn from them, and this is what we have done."