A 68-year-old aged care resident who died from a heart attack wasn't given CPR by staff because they incorrectly believed he had a do-not-resuscitate order.
Wayne Victor Rouse used a bell in his room at Tandara Lodge in northwest Tasmania to call for assistance on the morning of June 14.
Staff, who were busy with another resident, arrived eight minutes later to find Mr Rouse unconscious on his bathroom floor with no pulse.
Coroner Robert Webster, who investigated Mr Rouse's death, said staff did not commence CPR because they believed he had an active do-not-resuscitate order.
An ambulance was called and he was pronounced dead about 15 minutes later.
"Staff then located (Mr Rouse's) records and discovered that he, in fact, had an active resuscitation order," Mr Webster said.
Mr Webster said the failure to provide CPR was due to inadequacies in the aged care home's documentation and their communication to staff about a resident's wishes.
Mr Webster said medical evidence suggested Mr Rouse would not have been revived if CPR had been performed.
However, the absence of the potentially life-saving procedure was "contrary to his expressed wishes".
Mr Webster said the facility had addressed inadequacies, reducing the chances of a similar event.
The home's documents stated Mr Rouse's preferred treatments, including CPR, but the nursing handover sheet on duty indicated he was not for resuscitation.
Mr Rouse's cause of death was listed as congestive cardiac failure. He had also suffered from hypertension and chronic obstructive pulmonary disease.
The home has changed several protocols including implementing colour-coded signs in residents' rooms indicating their resuscitation status.
It has also introduced standardised document storage in the common staff area for residents' goals-of-care documents.
Tandara Lodge CEO Paul Crantock expressed his condolences to Mr Rouse's family and said the incident had been traumatic for all involved.
He said the home implemented changes within days of Mr Rouse's death.
Mr Webster recommended the home review staffing levels, noting there was only one registered nurse and one care worker rostered when Mr Rouse died.
"It is unclear how many residents the staff were caring for at this time and the usual staffing level is not known," Mr Webster said.
"If both staff are helping another resident, as occurred here, there is no one available for the rest of the unit."
Mr Crantock said the home had reviewed staffing levels and was seeking an additional night shift worker but there was difficulty attracting people to regional areas.
"We definitely have taken on board the comments the coroner made (and are) hopeful to have that position filled in the near future," he said.
