A review by the Saskatchewan ombudsman of a senior's death at a long-term care home found that staff failed to meet some provincial standards.
Mary McFadyen's report also says managers at Extendicare Sunset in Regina were not aware of the breaches, which included having a nurse pronounce the senior dead and failing to notify the coroner because the death was accidental.
Jessie Sellwood, who was 87, was taken to hospital after she fell and cut her leg on Dec. 23, 2013.
She was returned to the care home, but after increasing pain was sent back to the hospital two days later, where a doctor found her other leg was broken.
The woman was again returned to Sunset and died on Dec. 27 of congestive heart failure, although the report said the leg injury probably contributed to her death.
The ombudsman also says she found gaps related to fall prevention at the care home.
McFadyen makes several recommendations, including that officials with the care home and the Regina Qu'Appelle Regional Health Authority apologize to the senior's family. When the family initially asked for a copy of Sellwood's medical chart, care-home staff did not realize they were allowed to share her full file.
"Mrs. Sellwood's family did not get meaningful and timely answers to their questions," wrote McFadyen.
Family members took their complaints to the legislature and the health minister referred it to the ombudsman.
"Communication is vital to long-term care residents and their families -- whether it is the information shared when a resident is transported to or from hospital, or the information collected for an internal investigation, or information provided to families who have questions after the death of a resident," said McFadyen.
She added that the care home and health region have all her recommendations and are implementing them.
