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Montecillo Veterans Home and Hospital in some cases failed to document patient care plans, did not properly monitor pain relief and showed shortfalls relating to restraints used on people at the home, according the results of the recent audit, published by the ministry.
Meanwhile, the St Kilda rest-home has brought in a new nurse manager after the previous manager's paperwork was not up to scratch, a well-placed source said.
Montecillo chief executive Lynley Kloogh said the issues addressed were being dealt with but she otherwise declined to comment.
The facility is in the electorate of Dunedin South MP Clare Curran, who said yesterday she would seek advice from the Minister of Health on the issues raised by the audit, carried out in May.
Rest-homes are subject to certification audits every one to four years, after which they are certified for a set period, which depends on their performance in the audit.
Montecillo was last audited in November 2017, when several shortfalls were identified, including that there was not always a qualified first-aider on duty along with documentation failures in care plans.
The latest audit, undertaken by Health and Disability Auditing New Zealand for submission to the Ministry of Health, found more shortfalls than the previous audit.
This year's "areas for improvement" related to informed consent, internal audits, incident reports, education, timeframes, care plan interventions, evaluations, monitoring, medications, restraint management and infection control.
For example, several failures in Montecillo's infection control programme were uncovered by the auditors, which had not been reviewed on an annual basis or internally audited last year, as was required.
The only area where no shortfalls were identified were the eight standards under the "Safe and appropriate environment" grouping, which were all fully attained.
Auditors reviewed notes in one file from the rest-home and three from the hospital, which failed to show a consistent review by a registered nurse, including following-up reports of pain and discomfort.
One resident of the hospital did not have their bed sore reassessed after it developed, the audit found.
Auditors also reviewed 15 forms completed after "adverse events", including service shortfalls.
None of the forms identified opportunities to minimise risks of future incidents and no report was completed for a resident who suffered a bed sore.
As well, monitoring charts for residents who needed repositioning and "as required" pain medication were not properly completed.
Of all the audited standards, 37 were fully attained while 13 were only partially attained.
Five of those 13 were judged "low risk" and eight were "moderate risk".
The Otago Daily Times understands the nurse manager at the time of the May audit has been stood down from her post and will not be returning to Montecillo.
She declined to comment when contacted this week.
Southern DHB nursing director Sally O'Connor said as part of the audit and assurance process, two experienced registered nurses from the DHB spent a day at Montecillo.
"Such visits happen from time to time with care homes and other providers contracted with the DHB, and the nurses have not been seconded."
A spokesman for the Office of the Health and Disability Commissioner said it had received one complaint about Montecillo this year, relating to its complaints process.
Dunedin South MP Clare Curran said Montecillo was an important facility in her electorate, providing care for veterans and their dependants.
"On the face of it there seem to be some definite areas of concern in the audit report.
"I am seeking advice from [Associate Minister of Health] Jenny Salesa on the seriousness of these matters and the efforts Montecillo is taking to improve its practices and standards."