A rest home and three nurses have been criticised for failing to properly care for a resident with Alzheimer's disease after falling.
The elderly woman, who also had dementia, fell twice and later died after suffering a brain bleed.
Deputy Health and Disability Commissioner Rose Wall said nursing staff did not complete a full 24-hour period of observation after each fall.
"Nursing staff also did not calculate the woman's Glasgow Coma Scale (GCS) score, used to assess a level of consciousness, which was a requirement under the rest home's policy."
She said the woman went to sleep after the second fall, had vomited, and was less responsive when staff woke her the next morning.
"They called an ambulance, but did not describe the details of the fall or the head injury to the dispatcher, and said that the woman was safe to wait for an ambulance if there was a delay."
Deputy Commissioner Wall said the rest home's policy and documentation for neurological observations did not align with national best practice.
She added that the rest home staff lacked understanding about the length of time for neurological observations after a fall.
Wall made a number of recommendations, including that the rest home and three nurses provide written apologies to the woman's family and that the nurses have further training.