He found the man's weight and hydration levels weren't adequately monitored, his wound care poorly managed, inadequate steps were taken to manage his falls, and there was poor communication between staff involved in his care.
On one occasion, a nurse tried to feed him jelly beans because he had low blood sugar, but he was not fully conscious, causing him to choke.
He often fell over, which caused wounds, and he also had bedsore wounds, with one on his heel turning black.
The man's doctor told the commissioner normally a nurse would swab the wound if they thought it was infected, but this did not happen.
Mr Hill said there was no evidence rest home staff discussed the man's weight loss, frequency of falls, or wounds with medical staff until a severe wound was noted.
Eventually he was admitted to hospital with two gangrenous ulcers on his heels that could not be operated on and he died later that day. Mr Hill determined the rest home breached Right 4 (1) of the Code of Health and Disability Services Consumers' Rights for failing to provide services with reasonable care and skill.
It did not ensure adequate clinical oversight or orientation for its staff, or that staff complied with its policies, he said. He said the nurse manager and senior nurse should have sought medical advice for the man but they did not breach the code.
"Metlifecare Wairarapa is ultimately responsible for such widespread failures of its staff as, without staff compliance, policies become meaningless."
He also agreed with the staff who said the workload was excessive at the time.
The rest home, however, rejected this claim.
It said it accepted some employees failed the man in some specific areas, but the failings were not indicative of widespread failure by staff.
As a result of the investigation, it said changes were made to the management of pressure area care, assessment of wounds, individual care plans, and accessing expert advice.
It said over 2011 and 2012, all staff were trained focusing on the areas identified in the complaint.
Mr Hill recommended the rest home provide a written apology to the man's family.
The nurses had already apologised to the family, which he also recommended.
He recommended the rest home provide him a review of training provided to staff in relation to communication, diabetes management, prevention and management of pressure areas and falls, pressure ulcer care, and end-of-life care; evidence of training in pressure wound care, and wound assessment forms are recorded accurately and updated; and evidence of training updates.
Names are removed to protect privacy.
