Deputy Health and Disability Commissioner Rose Wall is now using the man's death in 2018 as a timely reminder to all retirement villages about their responsibilities to provide health and disability services to all residents and not just those receiving hospital-level care.
The man in his 80s was living in a cottage in a retirement village when he sought help from hospital staff after falling over and banging his head.
He was seen by a nurse in the hospital who checked the back of his head, his blood pressure and vital signs.
The nurse then cleaned his "superficial" wound and monitored him for 30 minutes.
The man, who was on a blood thinner, told the nurse he was okay and declined to go to the hospital, so went home.
The head nurse, who also helped the man, completed the incident form on the other nurse's behalf because he was a bureau nurse and did not have access to the electronic form. Parts of the form were left blank.The male nurse then called the man's daughter to tell her about the fall, but did not mention he had refused to see a doctor.
The resident was checked later that day by both a home support worker and a nurse.
The next morning the man called for help again and told the duty nurse he had a sore head and a lump on the back of his head.
The nurse called for an ambulance at 10am, but told the ambulance operator it was not urgent given the elderly man was still lucid.
A home support worker who did not have a first aid certificate then waited with the man and the nurse called several times to check how the man was until an ambulance finally arrived just after midday.
The man's condition continued to deteriorate and he fell into a coma after being admitted to hospital later that afternoon. He later died from the brain bleed.
While the resident did not have an agreement with the facility for care services, the agreement included that a medical practitioner would be on call at times for emergencies.
Wall said retirement villages with onsite rest homes and hospitals needed to recognise the professional responsibilities of their nurses to respond appropriately in such circumstances.
During HDC's investigation, nurses said their main responsibilities were in the hospital and they could not stay with the man. Another relief nurse said he was not aware of what was required for residents who lived independently in the village.
Wall said the care given to the man was not good enough and criticised two for not completing an incident report of the man, not fully informing the man's family about his refusal for extra care or providing a clear handover about his fall, including that he was on a blood thinner.
Another nurse was criticised for getting a home support worker who did not have a first aid certificate to stay with him while he waited for an ambulance, instead of staying with him himself. She also believed the nurse should have had access to his notes and carried out a better assessment of him.
The retirement village was ordered to apologise to the man's family, review its relevant policies and procedures and consider improving the information provided to village residents about emergencies, medical incidents and requests for assistance,
