A Health Information and Quality Authority inspection carried out at a Co Louth nursing home where 22 residents died during an outbreak of Covid-19 found there were staffing shortages, poor communication and in some instances a lack of adherence to infection control measures at the facility.
The inspection report at Dealgan House in Dundalk said families were not afforded the opportunity to be with their loved ones when they were dying and many were traumatised by what happened.
The inspection was carried out at the home on 27 and 28 May and followed the deaths of 22 residents.
The nursing home was informed of the inspection on 26 May.
There were 58 residents at the home on the day of the inspection. One resident was in hospital.
It's one of 31 inspection reports on nursing homes published today by HIQA, which looked at Covid-19 outbreaks, preparedness and residents deaths.
The report into Dealgan House in Dundalk details how the Chief Inspector of HIQA was advised of the outbreak at the home on 7 April.
It noted that in April more than 60% of the all staff - including 70% of the nursing staff - were unable to work due to contracting Covid-19.
The inspection said the facility experienced significant delays in accessing test results for residents and staff.
It noted that staffing shortages were further compounded by a number of staff unable to return to work until their test results came back.
HIQA said the senior management team was also significantly impacted by Covid-19, and therefore unable to work and oversee the care and services in the home.
The management team was reduced to the assistant director of nursing who continued to work throughout the outbreak.
As there were no administration staff to support nursing and care staff during the outbreak, telephones were not answered and communication with families broke down as a result, the report noted.
This created high levels of anxiety and distress as families did not receive accurate information about their loved ones.
During the two-day inspection, inspectors said staff spoke with deep respect and profound sadness about those residents who had died during the outbreak.
Families 'shocked and saddened'
The families of the residents who died in Dealgan House Nursing Home say they are "shocked and saddened" by many of the findings in the HIQA inspection report.
The families said they will be raising many of the issues with Health Minister Stephen Donnelly when they meet with him next week.
They say the report galvanises their calls for a public inquiry into Dealgan House Nursing Home.
"It is clear that this report will only add to the questions that we have about what exactly happened to our loved ones" the statement said.
"We are acutely aware of the ongoing situation of Covid-19 outbreaks in nursing homes and we believe that by examining what happened at Dealgan House Nursing Home, the wider lessons that are so badly needed by the health authorities can be learned and implemented in full to avert a similar tragedy ever happening again."
Dealgan House was found not to be compliant with seven regulations
Testimony from nursing and care staff described how staff remained on duty and worked additional hours to ensure that residents at end of life were not left alone.
However, there was clear evidence to show that during the Covid-19 outbreak communication with residents' families had not been maintained in all cases.
The home had not ensured procedures were in place during the outbreak to keep relatives informed of a resident's condition.
Relatives said their grief had been further compounded by the way in which their loved ones belongings had been returned to them.
Black plastic bags and boxes were used to pack and return residents' personal belongings and bereaved families reported to the inspectors how this insensitive arrangement added to their grief at what was already a very difficult time.
Many relatives who spoke with inspectors before and during the inspection were clearly traumatised by these events and a number of individuals broke down when they described their memories of this time.
Inspectors also spoke with residents and some expressed an understanding that something awful had happened in their home and that some of their friends and neighbours had sadly died as a result.
A number of them expressed their deep gratitude for how well staff had cared for them when they had contracted the Covid-19 virus, and told the inspectors how staff had helped them to remain positive and look towards a full recovery.
One resident told the inspectors that they were "sick of looking at the same wall for more than eight weeks".
The report noted that it was evident that the prolonged period of 'cocooning' was negatively impacting residents "wellbeing and increasing relatives" anxieties.
The nursing home was found not to be compliant with seven regulations, including infection control.
On the second day of the inspection, inspectors observed staff arriving at work already with their uniforms on, and not adhering to social distancing when checking having their temperatures checked.
Although the Covid-19 pandemic was an unprecedented event, inspectors found that the Covid contingency plan in place at Dealgan House did not work.
It said this significantly compromised the delivery of care and services for residents, and created high levels of anxieties and distress for their families.
While acknowledging that Dealgan House Nursing Home had gone through a very difficult and traumatic time, inspectors found that the management arrangements that were in place at the time of the inspection required significant improvement and focus.
The Director of Dealgan House nursing home Eoin Farrelly has welcomed today's HIQA inspection report.
He said the home is particularly happy with the recognition given to the dedicated staff who were under immense pressure at that time of the outbreak.
He said Dealgan House has always considered HIQA Inspections as constructive learning experiences.
He added that the report highlighted some areas that needed attention and the Nursing Home attended these issues immediately "so much so, that in the follow up inspection all residential care related regulations were deemed compliant".
Mr Farrelly said the home continues to take all possible steps to protect our residents and staff during the current surge.
He has also asked that everyone fully observe the Government restrictions so as to "bring this frightening surge under control and protect the elderly in our society".
Another nursing home TLC City West in Dublin was inspected unannounced on 23 July when it was experiencing a significant Covid-19 outbreak that was ongoing since April.
At that stage the inspection report noted that 74 residents had tested positive for Covid-19, 45 residents had recovered and 29 residents had passed away.
76 staff members also tested positive.
Although the centre had no positive cases at the time of this inspection, the outbreak was not declared over by the public health team.
An inspection was also carried out at Loughshinney Residential Home in Skerries, Co Dublin.
There had been two successive outbreaks of Covid-19 between April and July.
It was was found to be fully compliant with all 16 of the regulations inspected. It was found that the home had planned and prepared for Covid-19 from early on in the year.