Both assistants say they checked over the woman for injuries, but did not locate any bruising. One of the assistants noted as much in her clinical notes.
One of the assistants then notified the registered nurse working that evening and said she would check in on the patient after her dinner break. The nurse later told the commissioner that the assistant had said the patient was "absolutely fine".
That night, a nurse did not check over the patient - the result of the nurse "forgetting" the incident had occurred. The woman's family was not informed of the fall, nor was it recorded in the handover booklet for staff on the next shift.
The next morning, a nurse noticed discolouration on the woman's left knee and right shin. This discovery wasn't documented.
Staff examined one knee was larger than the other, and the patient appeared to be in discomfort.
Finally, at the end of a healthcare assistant's shift the day after the incident, the staff member noted their concerns for the woman, and detailed observations of her injuries.
The next day, a nurse read those progress notes.
At around lunchtime, a nurse noticed the patient's face was darkening. Shortly after lunch, a nurse documented: ""Left knee (inner aspect) appears to be causing [Mrs A] discomfort — flinching when touched. Pamol given at 1130hrs. Appears more comfortable."
Later that day, as the patient was being moved on a hoist, two healthcare assistants noticed a "blood-looking blister" on the woman's inner leg. The nurse's recommendation was to place a towel behind the leg.
At this point, family members of the patient got wind of the fall. The patient's daughter contacted the hospital and requested a formal assessment as soon as possible.
The next day, the woman was seen by a GP, by which point she was transferred to the emergency department. The fracture was diagnosed, and the woman underwent surgery.
Hospital apologises for failings
In her determination, deputy commissioner Rose Wall said the care provided by the hospital was not to an acceptable standard.
"This is exceptionally concerning, as Mrs A was a highly vulnerable consumer who was unable to communicate or advocate for herself. She was totally reliant on others to both protect and keep her safe."
According to Wall's findings, the hospital has subsequently written to the family of the patient and apologised for its shortcomings.
The deputy commissioner ordered a number of recommendations as a result of the incident, including an order that the hospital undertakes a review of its clinical policies and procedures, and implements a formal training programme for staff to learn how to appropriately report incidents.
Commissioner Wall also recommended the Nursing Council undertake competence reviews of two nurses at the centre of the complaint.
"In my view, robust policies and procedures in an aged-care setting are basic and fundamental to ensure older people receive services appropriate to their needs. These are vital to ensure staff receive adequate guidance and support to provide safe and effective health services on a consistent basis."
A subsequent Ministry of Health audit has found Golden Pond is compliant with the Health and Disability Services Standard.
