The Health and Disability Commissioner says an Auckland rest home failed an elderly woman suffering from an ulcer by failing to seek specialist advice in time.
Anthony Hill says the Edmund Hillary Retirement Village, along with its hospital manager and clinical manager, breached patient rights.
The unnamed 84-year-old woman was suffering from a pressure ulcer on her lower back when she died in hospital, after receiving care from the home.
The commissioner says the ulcer clearly deteriorated in a three-month period but staff failed to properly monitor and assess it, or seek specialist advice.
Mr Hill says there was also poor communication among staff about the ulcer.
Ryman Healthcare, which owns the rest home, says it has put measures in place to make sure a similar situation does not arise.