The Aged Care Commissioner has found Graceful Home Orewa Limited, which operates Pinehaven Cottage, breached the Code of Rights after a 92-year-old resident died following an unwitnessed fall in 2021.

In a decision released by the Health and Disability Commissioner, the facility was found to have breached the right to services provided with reasonable care and skill. The resident, referred to as Mrs A, had Alzheimer’s dementia and a history of falls. She was diagnosed with a left subdural haematoma after the fall and later died in hospital on comfort care.

The investigation found:

• Mrs A’s care plan was not updated after an interRAI assessment and did not give specific guidance for her known night-time wakefulness, toileting needs, or how to safely settle her overnight.
• There was no documented plan for the frequency of safety checks, despite a policy requiring at least two‑hourly checks or more as needed. A sensor beam was noted in her plan, but there was no evidence it was routinely checked.
• Staff did not follow post‑fall protocols on the night: the emergency bell was not activated, the carer who found Mrs A left her to seek help, and Mrs A was moved before the on‑call registered nurse was contacted.
• The facility’s adverse event investigation did not clearly identify the cause of the fall, nor was there clear evidence of a meeting with the family to discuss findings or of learnings being shared with staff.
• Three days prior, an altercation between Mrs A and a carer was not escalated to a registered nurse, despite guidance in her plan on de‑escalation and person‑centred approaches.

Mrs A’s daughter, who held enduring power of attorney, questioned whether the injuries were consistent with a fall from bed and raised whether police should be involved. HDC advised those concerns could be taken to Police, noting the Office’s role is to assess the standard of care. Mrs A’s death was not referred to the Coroner.

Graceful Home Orewa Limited told HDC it had acquired Pinehaven less than a month before the incident and argued it should not be held responsible for issues tied to the previous owner. The Commissioner’s nursing advisor noted that, regardless of a transition, staff are expected to practise to the accepted standard of care.

The Commissioner accepted advice that there were departures from accepted practice in three areas: falls risk management (mild to moderate), management of the sentinel event (moderate to significant), and the handling of the earlier altercation (moderate). The Commissioner found Pinehaven breached Right 4(1) of the Code.

Since the event, Pinehaven said it has provided additional staff education and:

• Implemented six‑monthly resident review meetings.
• Introduced a system to update care plans following interRAI assessments and the six‑monthly reviews.
• Created a Falls Focus Group with an event feedback process.

The provider has also, according to material reviewed by HDC’s nursing advisor, trained all staff on the nurse call system, added an audible alarm, and installed CCTV, and set up a falls prevention committee.

The Commissioner recommended Pinehaven provide a written apology to Mrs A’s family within three weeks and complete HDC’s online education modules within three months. The anonymised report, naming Graceful Home Orewa Limited (Pinehaven Cottage), will be sent to HealthCERT and Te Whatu Ora, and published on the HDC website for education purposes.

Mrs A’s daughters told HDC they want the outcome to lead to lasting improvements. One said: “I’m appalled and saddened at Pinehaven’s lack of care given to our dear mum … I do believe that Pinehaven haven’t been honest as to what exactly happened.” Another said the facility’s atmosphere changed around the time of new ownership and that contradictory accounts had left the family unconvinced the circumstances of the fall were clear.