A support worker has been told to apologise to the family of an elderly man, after lying over whether she visited the man in his home.
The man was found unconscious on the floor two days after the intended visit in 2018, and died shortly afterwards in hospital.
The elderly man lived alone and received in-home support services from a community health service, which included personal care every day.
The report from the Health and Disability Commission (HDC) found while the worker said she attended the Saturday session, GPS data shows she was at her own home the whole time.
The next day, another support worker did arrive at the house, but the man did not answer the door and, after contacting the community health service, they were advised they could leave.
On the Monday, a different support worker attended and when the man again did not answer the door, they forced entry into the house and found the man unconscious on the floor in a distressed state.
He was then taken to hospital where he later died.
Deputy Commissioner Rose Wall said clinical documentation were not sufficiently clear to determine when the man may have fallen, and so could not comment on whether a visit on the Saturday would have led to a different outcome.
"This report highlights the importance of home-support workers attending their scheduled appointments with clients, many of whom are very vulnerable," Wall said.
She recommended the worker apologise to the man's family, and also consider attending training on the importance of logging her attendance.
The community health service also faced criticism from the deputy commissioner for their failure to treat the man's family's complaint more seriously.
The family contacted the health service following the man's death, but their inquiry was not treated as a complaint and the service determined no further investigation was needed.
An internal investigation only began six months later following a complaint to the HDC by the family.
It was then that the support worker was interviewed and discrepancies were found in the information she had provided.
Wall said she considered the investigation was inadequate, delayed, and piecemeal.
The service has been told to consider whether staff attendance should be routinely monitored or randomly audited.
It has also been told to report back to the HDC following training on the management of complaints, investigations, and privacy.