A rest home that encouraged an elderly woman to walk on a broken ankle and hip breached the Health and Disability Code.
The Human Rights Review Tribunal found staff at Norfolk Court in Dargaville weren't properly trained and patient assessments were inadequate.
It identified several incidents. In one, a 73-year-old Alzheimer's patient became agitated. He was given sleeping pills and seen stumbling around the floor. The man tried to jump off a balcony after being given another drug, so was given a stronger dose.
He fell on the floor three times before a doctor stopped the medication. He fell again days later. A CT scan showed he had brain injuries. He died soon after.
An 82-year-old woman suffered four falls over 14 months. A nurse examined her after the final fall on February 21, 2009, and found no serious injuries.
A doctor, called at her family's request, also found nothing and the woman was encouraged to walk.
Five days later x-rays showed she had a fractured ankle and hip.
Staff said owner Stuart House was overseas and could not be contacted.
Bad care in rest home causes pain
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