A Canterbury rest home has been criticised for its lack of attention and responsiveness to a man's deteriorating condition.
Ultimate Care Karadean Court in Oxford, near Christchurch, has been penalised for the complaints, which date back four or five years.
The company insists it has improved since then.
The resident in his 80s had been admitted to the facility for hospital-level care.
He required interventions to manage his continence, hydration, medication, diabetes, podiatry, pressure areas, and pain.
But during his six years at the facility his health deteriorated.
In a report released today, the deputy health and disability commissioner Rose Wall said there was a lack of attention and responsiveness to the man's deteriorating condition by multiple staff, and a lack of oversight by the clinical managers.
He was eventually transferred to hospital after two unsuccessful attempts to administer antibiotics, and he subsequently died due to blood poisoning and a skin infection.
Wall found that there were a number of failings involving multiple staff at the facility.
The man's continence care was not properly reviewed, his podiatry reviews were not arranged for him; his diabetes was not adequately monitored; and his pain relief was not properly managed.
She was also critical of the inaccurate recording of the man's wound care documentation and monitoring of the man's pressure wounds, the failure to seek specialist advice in a timely manner, and the insufficient number of registered nurses available to provide oversight to junior staff.
"The provider had a duty to provide services with reasonable care and skill, and is responsible for the actions of its staff," Wall said.
"I consider that deficiencies in the care provided by multiple staff represent systemic issues at [the facility]."
Wall recommended that Karadean Court give training to its staff on pressure area prevention, pain management, and oversight by the clinical manager.
She also recommended it should audit compliance with policies developed in response to the complaint; review its staffing levels, induction and training programme, and equipment and supplies; and provide a formal written apology to the man's family.
The Deputy Commissioner recommended that the clinical managers undertake training on clinical documentation, care planning and assessment, wound care management, communication, and clinical leadership; and that they provide written apologies to the man's family.
The provider has been referred to the Director of Proceedings. The director could consider putting proceedings before the health practitioners disciplinary tribunal, the human rights review tribunal.
In an emailed statement to RNZ, Ultimate Care Group director of nursing and wellness Carole Kaffes said the company had worked with the commissioner to understand and correct the failings.
"The Ultimate Care Group has improved consistently in all areas that were identified within the Commissioner's report as well as other improvements over and above those recommendations," she said.
"These include staffing levels, training, a greater emphasis on wound care management and medication management.
"We continue to be consistent in our approach, to achieve the best quality outcomes for all our residents and feel we have been able to demonstrate this over the last four years since receiving the initial complaint.
"Since 2016, as part of the normal course of business, Karadean has been through two surveillance audits, and one certification audit by the Ministry of Health designated auditing agency, DAA Group. We are pleased that we have remained fully certified for a 36-month term to provide Hospital and Rest Home levels of care.
"Our apologies to the complainants have been genuine, and we regret the failings identified at the time to our policy and processes."