Nursing home had one staff nurse on duty for 44 residents on one weekend, report finds
One nursing home had just one staff nurse on duty for 44 residents on one weekend, while there was "inadequate oversight" at another nursing home where had been recent legionella contamination of the water supply.
The findings relate to two nursing homes inspected by the Health Information and Quality Authority, which published 60 inspection reports of different facilities.
At the HSE-run St Brendan's Community Nursing Unit in Loughrea, Galway, HIQA found "overall governance, infection control, risk management and fire safety precautions were poorly managed".
The Unit, which had 84 residents at the time of last September's inspection, had re-opened admissions following the contamination of the water supply with Legionella earlier last year.
Strict measures to manage the issue remain in place, but HIQA found there were still issues at the centre. It claimed the HSE had failed to ensure there was sufficient staff and criticised the high use of agency staff. It also referred to fire control concerns and "inadequate oversight of the controls and resources in place to manage identified risk".
The report said incidents of poor hygiene and infection control were noted by inspectors, including a bedpan tagged and dated 'clean' on September 4, containing organic matter, as did a shower chair within the sluice room.
At the Lystoll Lodge Nursing Home, Listowel in Kerry, the chief inspector had previously issued a notice of proposed decision to cancel the registration renewal for the centre following four negative inspections, but the latest review found residents were generally happy and that staff were kind.
However, despite the provider having instigated a number of improvements, some shortcomings persisted.
The centre had 50 staff and 44 residents at the time of last October's inspection but according to HIQA: "inspectors found that on one weekend there had been only one staff nurse on duty for 44 residents. This was a high-risk practice as supervision was not robust on these occasions, hence the risk of a resident missing a meal was higher and a medication documentation error was seen to have occurred."
HIQA found other examples of a lack of staff and also said not all activities were age-appropriate, such as ''colouring''.
Other concerns involved medicine management and maintenance of records.
In one case it found a "very serious omission" where a resident who had returned from hospital had not been given all their prescribed medication, while controlled drugs such as morphine were not properly accounted for nor recorded in the centre.
Elsewhere, the report into Clonakilty Community Hospital highlighted many areas of good practice, but among a small number of non-compliances HIQA said the HSE had failed to carry out a comprehensive review of occupancy levels.
Planning permission had been granted by Cork County Council for an extension to the premises but HIQA said "following this programme of works the majority of residents living in Clonakility Community Hospital would continue to be accommodated in rooms with four residents with associated difficulties in upholding the rights of residents and ensuring regulatory compliance".
It said the person in charge and assistant directors of nursing had progressed improvements as far as they could and that "further progress will require the support of HSE senior management".
