"His family had stressed to staff their wish that he be comfortable in his final days… [He] should not have had to rely on his family to advocate on his behalf for such a fundamental component of his end-of-life care," Wall said.
HDC investigators found the man's dressings were changed infrequently, there was a gap of seven days in one instance. It also revealed Evan was not offered regular showers, his room was found to be dirty, and maggots were found on his toes.
Evan had reported pain during dressing changes, and had suffered three falls.
During his time at the rest home he became increasingly unwell and lost weight and this was not monitored by staff, the report said.
The man's daughter Corina, who asked for her surname to be withheld, told the Herald in May last year learning of these care problems had deeply distressing.
"We knew he was going to die … but I did expect them to give him the basics of life – food, fluids, being kept clean and pain relief," Corina, who lodged the HDC compliant, said.
The report said: "There were delays in arranging reviews by a GP and podiatrist. In his final days at the rest home, his family raised concerns that his condition had deteriorated, and made a formal complaint, but there was no review or adequate response by senior staff."
Wall said the case highlighted the need to ensure that palliative care was appropriately planned to meet a person's end-of-life care needs.
The number of failings by the rest home and its staff pointed to an environment that did not sufficiently assist staff to do what was required of them, Wall said.
She was critical of the rest home's clinical services manager for not providing appropriate oversight of the nursing documentation and care planning, and was concerned she did not comply with the complaints policy.
As a result of the investigation, Wall recommended that the Nursing Council of New Zealand carry out a competence review of the manager, and that the staff member in breach apologise to the man's family.
The rest home owner was told to report back to HDC on the implementation of its own action plan developed in light of this case. It was expected to audit its compliance with protocols and review its palliative care policies, use this report as a basis for staff training and learning, and provide a formal written apology to the family.
Heritage Lifecare Limited accepted the recommendations and provided an outline of the actions it would take to meet the recommendations. It also gave HDC a written apology to forward to Evan's family.
The nurse also provided HDC with a written apology to give to the family.
