The Health Information and Quality Authority released their closing inspections on Mulross Nursing Home, Kilclare today, Thursday January 24. The nursing home closed on January 17 after all residents had been transferred to alternative care centres.
The shocking report says that the system in place at Mulross “increased the risk of medical errors occurring.”
The report cites persistent failings of the Health Act 2007 and found that there had been no person in charge of the home from September 2011 until May 2012. They also stated that there was poor wound management, nutritional assessment and pain management for residents.
The inspection report revealed that “do not resuscitate” directions were in some residents’ files. HIQA says there was no evidence available that the home had ensured this had been discussed with the residents, or their relatives, or the multidisciplinary team. The HIQA inspections in December and earlier this month found that there was no evidence that any communication had occurred with regard to resuscitation orders to ensure the residents had been involved in the decision.
HIQA reported concern about the care of a number of residents, one had a serious pressure sore that was not receiving suitable care, there was an incident of bruising to a resident which was not investigated, another resident who had an epileptic seizure was not monitored properly and a resident who had deteriorated from 13 December to 18 December 2013 did not receive a medical review.
It also stated that many residents had not been weighed recently even though they had been losing weight.
There were major problems with medical reports on residents, some residents had three medication charts and it was difficult to illicit from the medication administration records what medication had been administered to the resident.
There were also sewerage problems identified at the centre on 19 December 2012.
HIQA spent nine days at the nursing home inspecting it on dates from December 11, 2012 to January 11, 2013. Inspectors were concerned on the first day of the inspection regarding the fitness of the provider and person in charge and their ability to ensure the assessed needs of residents were met.
It was noted that “There were no complaints documented,” and that residents were well dressed and their clothing looked well cared for on the days of inspection.
The HSE took control of the home January 4, following the resignation of Stephen Buckley as the registered car provider, and the HSE assisted in the transfer of residents to other nursing homes, before it was officially closed on January 17.
The full story on the HIQA report will be published in the Leitrim Observer next week.