The Health and Disability Commission has criticised the care provided to an 87-year-old woman by a Whanganui rest home.
The woman was admitted to New Vista Rest Home for short-term respite care after a hip replacement in 2011.
A report by the deputy Health and Disability Commissioner found that the home breached the commission's Code of Rights by failing to provide continuity of services with reasonable care and skill.
It says that three weeks after admission, her anti-anxiety medication lorazepam ran out and it was two-and-a-half days before she received more.
While at New Vista, the woman had four separate falls, but the family was not notified until the fourth in which she hit her head.
The report found there was inadequate communication between staff and the woman's family.
Following a visit from a district nurse, the woman was found to have excessive swelling in her legs, with fluid oozing from them, and was admitted to hospital. The woman died shortly after being discharged to her home.
New Vista's facility manager Robyn Williams said the rest home is now under new management so it is not directly responsible for what happened.
In a statement on Monday, the Whanganui District Health Board said the investigation by the Health and Disability Commission was thorough and fair.
The DHB said it is confident that New Vista has addressed the issues raised and the rest home has invested in improving facilities, management and nursing leadership.