A dementia patient at the condemned Oakden nursing home screamed in pain for more than two hours because the wrong catheter was used while another's broken ribs went unnoticed for days, new Commonwealth documents have revealed.
The Aged Care Quality Agency's reports are among 1,900 pages of information tabled in Federal Parliament after Independent Senator Nick Xenophon demanded all documents about the disgraced facility be released.
The agency handles accreditation of aged care homes.
One document revealed in May last year a patient was distressed and screamed in pain because two clinical staff used a male instead of female catheter to obtain a specimen of urine.
Male catheters are longer than female catheters. The unsuccessful procedure went on for two hours.
Staff were reported to the national health regulator AHPRA for investigation.
In another incident in August last year, a dementia patient was punched by another resident, but two fractured ribs weren't detected until about a week later.
The patient's family was informed then.
One day after that, the injured resident was taken to the Lyell McEwin Hospital with damage to his spleen.
The mistreatment concerns came months before the State Government commissioned the chief psychiatrist to investigate Oakden after the Spriggs family blew the whistle.
But the Aged Care Quality Agency only became aware of the problems after it audited and subsequently sanctioned the facility in March this year.
Patients not properly dressed, unclean: report
Among other concerns noticed by the agency's inspectors were residents walking around without shoes or socks, two were unshaven and wearing torn clothes.
One female resident was found with her top on incorrectly, which meant she was exposed in front of other patients. No staff were around to help.
Food remnants were found on some residents' faces.
The agency also expressed concern that a staff member responded in a derogatory way when one resident asked if his wife would be visiting him that day.
In front of the resident the staff member said to another employee "just say yes, yes as he can't remember and it's just a waste of time".
Senator Xenophon said the Federal Government had not kept a close enough watch on Oakden over many years.
"The history of consistent non-compliance and the lack of follow up and remedial action is inexcusable," he said.
Yesterday the Independent Commissioner Against Corruption announced he was launching an inquiry into Oakden to identify whether there had been any maladministration or misconduct from local managers, to executives and ministers.