The Health Information and Quality Authority (HIQA) held nine inspections at Mulross Nursing Home, Kilclare from December 11, 2012 to January 11, 2013. As a result of the inspections’ findings and the resignation of the registered provider, Stephen Buckley, residents were transferred to alternative accommodation and the facility was closed on January 17.
Below we list the main findings of the closing report, published by HIQA last week.
• Medical and personal records were not maintained sufficiently by nursing and medical staff and could “increase the likelihood of medication errors.” Some residents had three medication charts and it was difficult to illicit from the records what medication had been administered to the resident.
• Wound management, nutritional assessment and pain monitoring and assessment did not comply with evidence-based practice and “posed a serious risk to residents.”
• Many residents had not been weighed recently even though they had been losing weight and were on nutritional supplements. A nutritionist saw some of the residents on December 17 and referred 7 to a dietician for further review.
• There was no person in charge from September 2011 until May 2012. The most recent person in charge resigned from her position on 20 December 2012 - this was the third person in charge since the provider registered the centre.
• Inspectors found on some files a line stating ‘Do not resuscitate’. There was no evidence available that the provider had ensured that this had been discussed with the resident or their relatives or members of the multidisciplinary team. There was no evidence of an assessment of the capacity of the resident. There was a policy on ‘Do not resuscitate orders’, which stated that there should be a discussion with all relevant parties and the outcome documented. There was also no care plan identified for those who were not for resuscitation.
• There was a resident with a grade 4 pressure ulcer who was not receiving suitable safe care. While this resident was being prescribed analgesia, there was no pain assessment or pain monitoring documentation in place to ensure that this resident’s care and welfare was protected. Nursing staff had not completed the wound assessment records consistently or completely.
• An incident of bruising to a resident, which had been recorded in the care file, had not been documented on an incident report and had not been investigated.
• On reviewing file of a resident with epilepsy, inspectors noted this resident had an admission to an acute general hospital in October 2012 as a result of seizure activity, but there was no documentation to support that this resident had been medically reviewed since returning from hospital. There was also no evidence of monitoring of blood analysis on this resident who was on an anti-convulsant treatment.
• One resident’s health had deteriorated from 13 December to 18 December 2012 and inspectors were not assured that this resident’s needs were being met. Inspectors verbally requested that all residents have a review by a medical practitioner.
• There was no individual evacuation plan in place for each resident detailing how they would be evacuated and what equipment would be required.
• There were sewerage problems at the centre on 19 December 2012. There was evidence of this at a manhole located directly adjacent to the left of the centre.