The Health Information and Quality Authority has criticised staff at a residential centre for people with disabilities in Co Tipperary for substituting blood-thinning medicines for a resident without seeking clarification from the prescribing doctor.
The health watchdog says the incident at a facility run by the Daughters of Charity Services in Roscrea had "potentially catastrophic effects". The facility is on the St Anne's campus near Roscrea.
The incident was discovered last June by a HIQA inspector during an unannounced inspection of the centre, which is home to 29 people, most of whom have severe to profound intellectual disabilities.
HIQA's report, which has just been published, says the visit was triggered after the centre's management notified the watchdog of an unspecified "adverse" and "significant" clinical event.
A medicines management inspector noted records of a resident receiving twice the prescribed dose of a blood-thinning medicine.
Staff explained that the liquid preparation of the medicine was not available on the day in question and that they had administered a tablet form of it instead.
However, the report says, the tablet was a combination preparation which contained two blood-thinning medicines and evidence was provided to the effect that this substitution and one other on the same day for the same resident, had not been checked with the prescriber.
HIQA says that "due to the potentially catastrophic impact of a resident receiving twice the prescribed dose of blood-thinning medicine without adequate medical oversight, the event amounted to major non-compliance with regulations".
The report adds that infection control standards in one of the centre's four bungalows were not acceptable because it was visibly unclean; and that fire containment works ordered following an inspection nine months earlier had still not been completed.
HIQA found that the Daughters of Charity Services responded adequately to the watchdog’s immediate action plan to address the issues identified.
HIQA releases reports concerning seven Daughters of Charity services
Inspection reports concerning a total of seven DOC centres were published today.
HIQA found that in four, while some improvements were required, they were providing services which were focused on meeting the needs of residents who were found to be generally supported to be independent.
The teaching of life skills supported these residents to participate in their preferred community-based activities.
However, HIQA says that significant risk was found in three of the seven DOC centres.
One, with 11 residents located in Roscrea town, was found not to be suitable to meet the assessed needs of residents.
Before the latest inspection last June, HIQA had issued it with a notice of a proposal to refuse and cancel its registration. This remains in place for the facility which HIQA identifies with the number 3948 .
HIQA found it had an inappropriate number of residents living together whose social care needs were incompatible and were not being met.
A centre run by Little Angels Association Letterkenny was found to have four major non-compliances. While there were good systems in place to support residents' social care needs, the governance, management and financial viability of this centre were of serious concern.
Significant fire safety concerns were found at a centre operated by North West Parents and Friends Association of Mentally Handicapped Children.
HIQA found that staff had not completed fire safety training, fire doors were ineffective and fire drills had not taken into account night-time staffing arrangements. However, inspectors found evidence of good management systems in the centre including good systems to support residents' healthcare needs.
Another report on a Nua Healthcare centre in Kildare concerns an inspection triggered by unsolicited information received by HIQA about the safeguarding of residents, infection control and risk management.
Inspectors found that the information was substantiated and four major non-compliances were identified.
Reports on three centres run by St Catherine's Association for children with disabilities based in Co Wicklow found that while there had been some improvement since previous inspections, there continued to significant failings in areas such as the oversight of healthcare needs as well as in admissions and contracts for the provision of services.
In all, 19 reports on residential services for people with disabilities were published today by the watchdog.
In a statement HIQA says the ten of these inspections found that, in general, the provider was ensuring good levels of compliance and focusing on promoting the quality of life of residents.
