In a report released today, Aged Care Commissioner Carolyn Cooper found that the care facility run by Presbyterian Support Otago and three caregivers breached the man’s consumer rights under the Code of Health and Disability Services.

The incidents were discovered after the man had moved into the care facility’s dementia unit a month earlier when his wife was no longer able to care for him at home.

He was referred by a district nursing service.

His progressing dementia and other medical conditions meant that he needed significant assistance with daily living, such as mobility and personal care.

A nursing note from August 3, 2019, recorded an incident during which the man had become “physically and verbally aggressive” when staff tried to help him with toileting after a fall.

Later that day, a caregiver note showed that toileting was one of his “biggest triggers” for aggression.

Nursing staff held discussions on how best to manage his personal care, and how to prevent agitation, which included the man hitting out at staff, and on one occasion grabbing a caregiver’s arm.

The family was concerned that staff might be contributing to his behaviour and installed a hidden camera in his room.

In the first incident on the night of September 18, 2019, the video footage captured a caregiver “shouting and speaking loudly” at the man in an aggressive and abrupt tone for about eight minutes, while staff tried to get him to move so they could change wet bed sheets.

The caregiver was seen gesturing at him “angrily” with her finger while failing to adequately communicate or explain what was happening.

Video footage from early the following morning showed a second caregiver entering the room and attempting to place a continence product on him.

The video footage showed she had instructed rather than assisted with her comments including that she told the man to “hurry up” and that she did not care if he pulled the product on.

The caregiver said she was “emotionally drained and exhausted” from working with the man, and had not had allocated breaks throughout her shift.

She later acknowledged that she had not behaved appropriately and that she should have remained calm, slowed down, and spent more time helping the man.

PSO later acknowledged that rostering issues may have contributed to the incident.

After seeing the footage, the family raised a complaint with Presbyterian Support Otago (PSO), which operated the facility.

PSO investigated and confirmed the behaviour was not in line with the organisation’s standards.

It told a family member it was “extremely sorry” for failing to safeguard the man’s wellbeing.

Cooper said its report highlighted issues with workplace culture at Iona Home and Hospital, which contributed to the breaches, including staff not feeling empowered to report inappropriate behaviour and a lack of proper oversight and support.

It also highlighted issues with care planning, resourcing limitations and a delay in investigating the incidents related to the man’s behaviour.

PSO acknowledged that even though the investigation was started quickly, it was several months before it was concluded and the family was notified of the outcome.

She found two caregivers breached the code by failing to treat the man with respect or provide services of an appropriate standard.

A third caregiver failed to intervene or report the abusive behaviour.

Cooper said concerning the first two caregivers, the conduct displayed on the video was never acceptable, and it was disappointing that the third did not speak up or intervene.

She said the care facility was found in breach of the code for failing to ensure the man received services that complied with legal, professional and ethical standards.

“In my view, the widespread and repeated nature of these actions by caregivers at PSO reflects a pattern of poor care and a failure to comply with policy and legal standards, for which ultimately PSO is responsible,” Cooper said.

She said PSO had a responsibility to prevent issues of abuse through appropriate selection of staff, training, rostering, oversight, and performance monitoring.

PSO said it had since put in place changes to improve staff training, culture and care practices.

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.