Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. Nursing Home Number of Residents Registered for 14 Nursing Home Address Proprietor Proprietor s Address (if different from above) Person-in-Charge of Nursing Home Date and Time of Inspection(s) Riverview Nursing Home 12 on 14.08.08 12 on 15.08.08 13 on 11.09.08 Dublin Road Trim Co. Meath Ms. Donna Quinn Mary Katherine Moran Date report issued 12 th September 2008 Summary of previous report findings 14/08/2008 10.20 Hrs 1300 Hrs & 14.30 Hrs 18.15Hrs. 15/08/2008 11.00 hrs 13.05 hrs. SEHO 11/09/ 2008 Further to the previous inspection dated 25 th & 26 th March & 14 th April 2008 the following Articles have been satisfactorily addressed: Article 5(a), (b) &(g), Article 27.1(b), Article 18.1 (b), Article 14 (a) The following Articles have been Partially Addressed Article19.1(f) Article 10.2 The following Articles have not been Addressed: Articles 11.2(a), (b)& (f), Articles 14(b) & (d), Article 10.5(d), Article 15(g) Article 19.1 (d) Inspection Report Findings Compliance status Current Inspection Summary Findings Findings of latest (unannounced) inspection which took place on 14/08/2008 & 15/08/2008 & 11/09/2008 The inspectors findings based on the current nursing home inspectorate regulations are as follows: 1
Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. Under Care & Staffing the nursing home was compliant with 18 out of 21 regulations. On the basis of this inspection and under current nursing home regulations, there are issues that need to be addressed as outlined below in relation to the Care and Staffing. Summary Findings of Current Nursing Home Inspection Under Management the nursing home was compliant with 27 out of 27 regulations. On the basis of this inspection and under current nursing home regulations, there are issues that need to be addressed as outlined below in relation to Management. (This section should be deleted if no noncompliances have been recorded) Under Physical Environment the nursing home was compliant with 6 out of 11 regulations. On the basis of this inspection and under current nursing home regulations, there are issues that need to be addressed as outlined below in relation to the Physical Environment. Based on the most recent nursing home inspection the nursing home is non-compliant under one or more regulations. For more details see below. Article 27.1 The registered proprietor and the person in charge of the nursing home shall: (a) take adequate precautions against the risk of fire, including the provision of adequate means of escape in the event of fire and make adequate arrangements for detecting, containing and extinguishing fires, for the giving of warnings and for the evacuation of all persons in the nursing home in the event of fire, and for the maintenance of fire fighting equipment ; On the day of Inspection it was noted that the fire panel in the nursing home was registering a fault, it was noted in the nursing home records that the Registered Proprietor had been informed of a defect in the fire detection system on Monday 11 th August 2008. It was further noted on review of the fire records that on the most recent service of the panel in April 2008 the service engineer had not certified the panel but instead recommended a complete upgrade of the fire panel, this recommendation had not been addressed. Compliance/Non Compliance 2
Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. At 12.50pm on request from the Designated Officer the RGN telephoned the service company to ascertain whether the panel would activate the fire alarm in the event of a fire given the fault on the panel. The company would not give an assurance that the fire panel would do so. The Designated Officer discussed this at length with the proprietor and advised that the panel would have to replaced or repaired before close of business. At 18.00 hours the panel was repaired. The registered proprietor and the person in charge of the nursing home to ensure that fire detection systems or equipment necessary for the giving of warnings is adequately and properly maintained and checked regularly. The Registered Proprietor and Person in Charge should ensure that where recommendations are made by appropriately qualified persons in relation to replacing or repairing fire detection systems or other fire equipment that these are implemented in a timely manner having regard to the health, safety and welfare of all residents and staff in the nursing home. Provide the nursing home inspectorate with the full details of the actions necessary to bring the fire alarm system up to standards as required and dates of their proposed implementation. Within 24 hours of receipt of this report Article 10.5 The Registered proprietor and the person in charge of the nursing home shall ensure that;(d) a sufficient of competent staff are on duty at all times having regard to the of person maintained therein and the nature and extent of their dependency 1. On the day of inspection the RGN on duty was unable to advise the Designated Officers of the names and diagnosis of the residents. 2. The Care Assistant on duty was unable to advise the Designated Officers of the location of the fire panel. 3. The relief chef was rostered to work for 16 days without a rest day. 4. One qualified staff nurse and one care assistant were on duty to provide care for 12 residents 2 of whom were assessed as being highly dependent 8 were assessed as being of medium dependency and 2 low dependency. 3
Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. The dependency assessment tool used provides for a rating scale of Low (16 & below), Medium(17-31) and High(32 & above), therefore the dependency level of the majority of the resident profile is medium dependent. It was noted that the majority of the residents required assistance with all activities of daily living. This is a recurrent non compliance having been noted in the report further to inspection on 31.08.2007 1 Staffing levels need to be reviewed to ensure that sufficient s of competent staff are on duty at all times to meet the needs of all residents based on their nursing assessment and dependency level and also to ensure adequate staffing levels are maintained and additional staff are accessible as/when required in order to meet the needs/demands for the resident profile and service. 2. The Person in Charge should undertake an indepth analysis (using an evidenced based tool while referencing recognised benchmarks), of the professional responsibilities, clinical practices, and nurse management input required based on the resident profile per shift. The aim of this analysis is to establish current and determine future appropriate nurse to patient ratios. 3. Take cognisance of the layout of the nursing home which consists of lower ground, ground floor and the first floor and ensure staffing levels are maintained to reflect the safety and dependency needs of the residents within each level of the nursing home. Within one month of receipt of this report Article 19.1 (d) In every nursing home the following particulars shall be kept in a safe place in respect of each dependent person an adequate nursing record of the person's health and condition and treatment given, completed on a daily basis and signed and dated by the nurse on duty. 1. On the day of inspection it was noted that the daily record of nursing care for all residents was based on summation. There is a lack of individualised recording of care or referencing to care plans for all of the residents. 2. The medication *** for Resident ** was increased on 31.07.08 as referenced in the nursing progress notes. However the residents care plan was not updated to reflect this 4
Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. change until 11.08.08 and on day of inspection a detailed care plan or behavioural management plan was not in place. 1. The daily nursing record should give details of care given to the resident by the nursing staff during their shift. The daily evaluation should reflect the care required by the resident as per their care plan in order to evaluate effectiveness 2. The admission process and subsequent assessment tools used should be consistent with a nursing home policy and reflect best practice guidelines. All identified needs should be integrated into a plan of care for each individual resident. 3. All information documented should be factual. Summation to be avoided and reference to current care plans should be entered in the daily progress notes in order to evaluate effectiveness. Narrative notes should be completed on a daily basis to give a picture of the resident s condition and care. They should provide a record against which improvement, maintenance or deterioration in the resident s condition can be judged. 4. The person in charge to ensure all nursing staff refer and adhere to An Bord Altranais guidelines on Recording Clinical Practice,2002 Within 24 hours of receipt of this report Article 29 (a) The registered proprietor and the person in charge of the nursing home shall make adequate arrangements for the recording, safekeeping, administering and disposal of drugs and medicines 1. The Designated Officers noted that an open tube of Fucidin Ointment was lying on a window sill in the Nurses Office. The medication had the initials of the name of a resident written on it in black marker and did not have a pharmacy label identifying to whom it was prescribed. On enquiry the Registered Nurse on duty advised the Designated Officers that this ointment was currently being administered to resident ** 2. The following medications were out of date on the day of inspection; Spiriva 18mcg capsules (2 boxes) expired 08/2006 Motillium 30mg suppositories expired 07/2008 5
Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. 3. The following medications were prescribed for former residents and had not been returned to pharmacy for disposal; Lexotan 1.5mg (2 boxes) and Risperadol 0.5 mg (2 boxes) The registered proprietor and person in charge: To ensure all nursing staff adhere to An Bord Altranais Guidance to Nurses and Midwives on Medication Management July 2007. Make adequate arrangements for the recording, safekeeping, administering and disposal of drugs and medicines. Implement a system whereby prescribed medicinal products are checked and disposed of appropriately. Update and Implement Nursing Home policy to reflect best practice. Within 24 hours of receipt of this report Article 29 The registered proprietor and the person in charge of the nursing home shall: (b) ensure that the treatment and medication prescribed by the medical practitioner of a dependent person is correctly administered and recorded. On the day of inspection it was noted that the nursing records of resident ** indicated that *** cream was being applied to the resident s groin, however on enquiry the RGN stated that this cream was being applied underneath the residents breast area. The medication being applied did not have a pharmacy label attached to identify the area to which the ointment was to be applied. The *** cream was prescribed for short term use for skin around a colostomy site, on 7/05/08, topically for 7 days by the GP, the nursing administration sheet for 12/8/08, 13/8/08, and 14/8/08 showed that it was applied on these dates, without a current prescription, signed by the General Practitioner. The registered proprietor and person in charge: To ensure all nursing staff adhere to An Bord Altranais Guidance to Nurses and Midwives on Medication Management July 2007. All medications to have a pharmacy label attached to ensure that the treatment prescribed is correctly administered, and should be correctly stored in a locked cupboard. All topical medications to have a commencement date clearly indicated to ensure the treatment is given only for the prescribed length of time and is safely disposed of on completion. 6
Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. A clear care plan must be in place and reviewed following completion of any prescription of short term topical antibiotic cream. Within 24 hours of receipt of this report Article 27.1 The registered proprietor and the person in charge of the nursing home shall; ( d ) ensure that emergency lighting is provided in the home; The emergency light over the fire exit door in the ensuite bathroom of room ** was not working on the day of Inspection Repair or replace to ensure the emergency lighting is in full working order Within 24 hours of receipt of this report Article 11.2 (a) In every nursing home there shall be provided suitable and sufficient accommodation which meets the minimum standards as follows adequate accommodation and space in single and shared sleeping rooms and portable screens or screening curtains to ensure privacy for individual persons. On the day of inspection it was noted there was insufficient screening in the * and ** rooms to ensure privacy. This is a recurrent non compliance having been noted in the report further to inspection on 31.08.2007 and 25.03.08 Ensure adequate screening is installed in all * rooms and ** rooms Within one week of receipt of this report Article 11.2 (b) In every nursing home there shall be provided suitable and sufficient accommodation which meets the minimum standards as follows adequate day space for each person in an area separate from the circulation and sleeping areas and adequate dining and sitting space for mobile persons. On 14.08.2008 it was again noted that the dining room space does not meet requirement for 14 patients. Though it is adequate for the of mobile 7
Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. resident s currently utilising it (generally no more than 5 residents at any one time as per SEHO) The space is compromised by the storage of a food freezer and mirror which must be removed. This is a recurrent non compliance having been noted on previous inspection on 14.04.08, 25.03.08 & 31.08.2007 Both of these items to be removed immediately and stored appropriately Within 48 hours of receipt of this report Article 11.2 (f) In every nursing home there shall be provided suitable and sufficient accommodation which meets the minimum standards as follows suitable and sufficient equipment and facilities having regard to the nature and extent of the dependency of the persons maintained in the nursing home 1. On the day of Inspection there were 2 commodes and one hoist stored in Room No. *. A hoist continued to be stored in the assisted bathroom 2. The covers on the lids of commodes in rooms * & * were worn and the foam exposed, thus making it difficult for the equipment to be thoroughly cleaned and fit for purpose. 3. On 14.08.08 it was noted that the carer on duty was bringing soup to those residents who preferred to have it in their rooms. However, a bed table was not available in every room and the carer was observed bringing tables from room to room to facilitate the residents enjoy their soup safely. 4. It was noted that in Rooms *, *, * & * Commodes or Urinals were left with the residents overnight as part of their overall continence management programme. In total the Designated Officers noted that of the total of resident s half required toileting aids. However despite the level of dependency of the residents, the reliance on toileting aids and the nursing home policies on Infection Control, Norovirus and MRSA all of which refer to the use of a bedpan washer, the nursing home does not have a bed pan washer to decontaminate this equipment effectively. 1. Provide a store room large enough to safely store all necessary aids and equipment. This is a recurrent non compliance having been noted on previous inspection on 14.04.08, 25.03.08 8
Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. 2. Repair or Replace the covers on all worn commode lids. 3. Provide sufficient bed tables so that there is one at every bed. 4. The Proprietor to ensure a bed pan washer is provided in order that all equipment is effectively decontaminated as required by the evidence based policies in place in the nursing home. 1. Within two weeks of receipt of this report. 2& 3 Within one month of receipt of this report 4 Within two months of receipt of this report Article 11.2 In every nursing home there shall be provided suitable and sufficient accommodation which meets the minimum standards as follows (j) emergency call facilities are provided at each bed; Further to the investigation of a complaint in September 2007 in relation to the answering of call bells and the subsequent outcome of the complaint investigation issued to the Registered Proprietor in November 2007, the existing call bell system was to be upgraded or replaced to meet the needs of the residents and the staff. As the nursing home consists of three levels it is necessary that staff are alerted as to which bell is activated from all floors of the nursing home by means of a personal device or a display panel on all levels. The Registered proprietor and Person in Charge to fully comply with the s of the Outcome of the Complaint Investigation Report dated 23 rd November 2007. The Registered Proprietor and Person in Charge to submit details and timeframe in which this issue will be completely and satisfactorily addressed. Within 48hours of receipt of this report. Article 15. The registered proprietor and the person in charge of the nursing home shall ensure that: (g) adequate arrangements are made for the proper disposal of swabs, soiled dressings, instruments, disposable syringes and sheets, incontinence pads and other similar substances and materials. On the day of Inspection it was noted that a clinical waste bin is still not available in the sluice room of the nursing home. This is a recurrent issue and was 9
Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. discussed at length with the proprietor on 25.03.08. The Proprietor advised the Designated Officers that contact had been made with a healthcare waste company with a view to arranging a collection service, however given the size of the nursing home it was proving difficult to engage a service. The registered proprietor and nurse in charge: To ensure all staff adhere to Nursing Home disposal of contaminated waste policy. To place a clinical waste pedal operated bin in the sluice room. To ensure all staff receive education on how to dispose of clinical waste. To engage the services of a clinical waste disposal company to dispose of clinical waste. To submit a copy of the contract/agreement made between Nursing Home and clinical waste collection company. Within two weeks of receipt of this report Article 14(d), The registered proprietor and the person in charge of the nursing home shall; ensure that a separate well ventilated room is provided for sluicing and for the storage of dirty linen. The ironing press for bed linen is stored in the sluice room where clean bed linen is brought for ironing. The laundry dryer is also situated in the sluice room. Remove ironing press and dryer from sluice room. Within two weeks of receipt of this report. Article 11.2 In every nursing home there shall be provided; (g) suitable and sufficient accommodation which meets the minimum standards as follows bed and bedding appropriate to the dependency of each person and suitable and sufficient furniture and other necessary fittings and equipment. On the day of inspection it was noted that the sheet on the mattress of the bed in Room * was very worn and frayed. Replace this and all other worn or frayed bedding. Within 24 hours of receipt of this report. Article 12 The registered proprietor and the person in 10
Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. charge of the nursing home shall (a) ) take precautions against the risk of accidents to any dependent person in the nursing home and in the grounds of the nursing home On the day of Inspection it was noted that three large cylinders of gas were free standing immediately outside the fire exit door of bedroom No. *.and posed a risk of accident to any resident using the grounds of the nursing home. That the cylinders be encased or otherwise made safe to prevent the risk of falling and injuring a resident. Within 48 hours of receipt of this report Article 15. The registered proprietor and the person in charge of the nursing home shall ensure that: (f) bed linen, disposable sheets and incontinence pads are changed as frequently as may be required for the comfort and well-being of the person,; On the day of Inspection it was noted that although resident ** was out of bed since 08.30 hours and that her bed had already been made, the coverlet of the bed was very stained and required changing when viewed at 11.00 hours. This was brought to the attention of the RGN in charge who ensured the cover was changed immediately. The proprietor and person in charge to ensure that all bed linen is changed as frequently as may be required for the comfort and well-being of the person Within 24 hours of receipt of this report. SEHO Article 14 The registered proprietor and the person in charge of the nursing home shall (a) ensure that the nursing home and its curtilage is maintained in a proper state of repair and in a clean and hygienic condition The manhole cover at the western gable is defective/broken. The gully grating was missing at the rear of the premises. Towel holders are not provided in the bedrooms for the disposable towels. There is loose wiring in the nurse s station and in the middle three bedded room. The handrail of the banisters is in not clean. Replace the manhole cover at the western gable and replace the grating on the gully at 11
Health (Nursing Homes) Act, 1990 and the Nursing Homes (Care and Welfare) s, 1993. the rear of the premises. Provide towel holders for disposable towels. Encase the loose wiring in the nurse s station. Clean the handrail of the banisters and include on the cleaning programme Within 48 hours of receipt of this report All regulations, their reference s and the details of those regulations can be viewed in Nursing Homes (Care and Welfare) s, 1993. Comments and recommendations made by the inspection team as a result of the inspection Comments and Recommendations Recommendation of SEHO Without prejudice to the issues outlined above I recommend that. The refurbishment which took place in 2006 and early 2007 be completed and that the laundry and sluice be upgraded to the standard of the remainder of the nursing home. This report has been completed/issued by Noel Mulvihill, LHO Author 12