Staff at an Australian nursing home ignored complaints of pain from an elderly stroke patient to the point a catheter had "tunnelled into his penis" — in another case of shocking neglect heard at the aged care royal commission.

Key points: The Australian Nursing and Midwifery Federation gave evidence

The Australian Nursing and Midwifery Federation gave evidence A survey of nurses by the federation revealed a serious case of neglect

A survey of nurses by the federation revealed a serious case of neglect Another medical expert said overuse of psychotropic medication was also a problem

GRAPHIC CONTENT WARNING: This story contains content which some readers might find distressing.

The Royal Commission into Aged Care Quality and Safety — which began hearing evidence in Adelaide on Monday — has heard from the medical profession about how poor quality and safety in nursing homes could impact the health and wellbeing of residents.

Australian Nursing and Midwifery Federation federal secretary Annie Butler told the commission about the impact of nursing shortages in the aged care sector.

She was asked about one case of neglect that was raised in a survey undertaken by the federation.

It stated that an agency nurse working in an aged care facility was told to administer paracetamol to a man because it helped him sleep at night.

"I asked further and was told the gent, who was aphasic, post (stroke) and very vulnerable, has a sore penis," the nurse stated.

"He was grimacing as I approached and asked if I might look. He nodded.

"He had a urinary catheter and instead of exiting from the meatus (opening) the glans had a split down the side, to the level of the shaft — it looked like a split hot dog."

The nurse stated she was "blown away" that staff had not reported the erosion as it was happening, took any steps to prevent it and that no one had bothered to look for the source of his pain.

"I am still horrified to this day — the wound was not new, it took time to erode through, with pressure from the (catheter) tunnelling into his penis," the nurse said.

Ms Butler said handover between medical professionals was one of the "areas of greatest concern".

"It's one of the areas that tends to get missed and sometimes is not even allowed," she said.

Psychotropic drugs are the go-to treatment for behavioural problems

Earlier in the inquiry, the commissioners were told the use of psychotropic drugs in Australian nursing homes should be a "last resort" but are instead the go-to treatment for behavioural problems, increasing the number of deaths, strokes and falls.

Australian and New Zealand Society for Geriatric Medicine's president Edward Strivens said he had seen occasions where psychotropic medications — antipsychotics, antidepressants and sedatives — were "used inappropriately".

"If we treated 1,000 people for a few months with antipsychotic medications we would get some improvements … in some of those target symptoms in around 10 per cent, maybe 12 per cent, of people," he said.

"However, we see an excess of 10 extra deaths in those people and 16 strokes as well as around 10 to 12 per cent of people more likely to fall over.

"So they do work, for want of a better term, but the side effects will often outweigh the possible benefits.

"They are a last resort but too often we see them used as a first resort and the use of medication should never be a substitute for good quality care."

Professor Strivens said about 80 per cent of older Australians in residential care with dementia were on at least one psychotropic drug, but only up to 10 per cent of those people had "severe symptoms".

"When all you have is a hammer, every problem looks like a nail," he said.

"I think this is one of the issues with antipsychotics, it far too often becomes the first step to look at say, managing someone who's presenting with agitation, sometimes physical outburst, rather than actually looking at the reasons behind this.

"And when we're looking at these conditions more as a cognitive disability this can actually be due to the physical changes that happen in the brain."

History could be key to understand behavioural problems

He said a person's "life story" needed to be taken into consideration when aged care workers were trying to manage behavioural problems.

"I saw a gentleman not that long ago who was a baker and used to getting up at [2:00am] every morning," he said.

"He would continue to get up at [2:00am] in the morning but within the setting of his residential care facility that was a potential problem to the facility.

"It wasn't necessarily a problem to him."

The royal commission into aged care heard from members of the medical community. ( AAP: Glenn Hunt )

Professor Strivens said there was currently no cure to reverse or halt the progression of dementia, but Australia needed to look at "how to live well with dementia".

"Things like exercise, diet, attending to middle-life vascular risk factors, things like high blood pressure, high cholesterol, risk of stroke, heart disease," he said.

"Treating that in midlife has a potential impact later in life."

Personal care workers are part of an 'unregulated workforce'

Also giving evidence was Australian College of Nursing ageing policy chair Deborah Parker, who told the commission that many people working in nursing homes were part of an "unregulated workforce".

"We would view assistance in nursing as what we would call the unregulated workforce in comparison to the registered nurses, enrolled nurses, where we're legislated to practice," she said.

"If we have an error in our practice, then we can get reported to the Nurses Board of Australia and that will be investigated.

"If we're found that we were in error, that will be publicly available against our registration."

She said training for personal care attendants was limited.

"They may go through without doing extensive training on dementia," she said.

"But it's a short course and so it really is, is it fit for purpose for the emergent needs of the client group that we're seeing?"

Professor Parker said to work as a personal carer in a nursing home, the minimum qualification was a six-month TAFE certificate.

On Tuesday, the inquiry was told that shocking cases of elder abuse exposed by the ABC's Four Corners program were the "tip of the iceberg", with staff shortages contributing to the problem.

The Combined Pensioners and Superannuants Association (CPSA) of NSW policy coordinator Paul Versteege said the current care model was flawed because it relied on staff to self report assault cases.

"We take the 'tip of the iceberg' approach, not necessarily that the horrific assaults that we have seen on the ABC Four Corners program happened as a matter of routine, but it is indicative of almost everything that is wrong with the residential aged care sector," he said.

Commissioners Richard Tracey QC and Lynelle Briggs will hear from hundreds of witnesses throughout Australia before they deliver their final report in April 2020.