Later an incomplete pain assessment tool was carried out, a fax was sent to a general practitioner for pain medication, and something for Mr A's behaviour, but staff did not request a GP review.
A report released by deputy health and disability commissioner Rose Wall released yesterday, found the rest-home breached the code of Health and Disability Services Consumers' Rights (the Code) for failures in its care of Mr A with a broken leg in 2018.
As the man continued to deteriorate and his pain worsened, a registered nurse sent another fax to the GP requesting a review but it was not received.
No further pain assessment was undertaken and the review request by the doctor was not followed up.
When the doctor finally came the following day, it was discovered the patient had not been weight bearing for two days and the doctor diagnosed a fractured neck of the left femur.
Mr A was then transferred to hospital by ambulance where he was diagnosed as having a fracture of the femur and left-sided pneumonia.
He died two days after he received surgery on his fractured hip.
One of the nurses involved said in the report; "reflecting back on this incident I wish I had just sent [Mr A] to hospital to be checked over. I apologise for the time delay ... and this has changed my nursing practice immensely."
"I will never hesitate to get a patient checked and will follow my gut instinct more."
Wall said the report highlighted multiple staff failures to use an appropriate pain assessment tool and monitor his pain adequately.
"There was also a lack of urgency in obtaining a GP review, no referral or attempt to transfer the man to hospital was made following the delayed GP review, and written communication with the man's GP was inadequate," she said.
Wall recommended that the retirement village undergo audit compliance with its falls management plan and the use of a new fax template and the amended fax referral document.
The retirement village has apologised to the man's family.
Because Mr A was cognitively impaired and no longer in a position to articulate his concerns clearly, the onus for assessing him and identifying the likely reason for his agitated state lay with Rowena Jackson, Ms Wall said.
Cheyne Chalmers, chief operations officer of Ryman Healthcare, which owns Rowena Jackson, said yesterday she fully accepted the findings of the report.
"We have apologised to the family involved — we regret the pain and distress caused to our resident and his family and accept that we should have done better.
"We are genuinely sorry for what happened, and lessons have been learned."
While appropriate policies had been in place, they were pointless if they were not followed, she said.
"It is Ryman's responsibility to support its staff to ensure they are aware of policies and that they comply. It is also Ryman's responsibility to foster a culture of compliance."
