The Health Information and Quality Authority has revealed that records at a residential centre for people with disabilities show that one resident was fed only 2% of his or her recommended nutritional and fluid intake on a particular day reviewed by the watchdog.
The inspection report of the west Dublin centre, which is run by Stewarts Care, also found that it had failed for many months to provide a safe service to residents and to protect them from abuse.
Today's report of last December's unannounced inspection of Centre Number Three at Stewarts' Adults Services Palmerstown in Dublin comes on the heels of a damning HIQA report last July which prompted the watchdog to threaten to deregister the facility.
The campus-based centre, which is home to 38 persons with disabilities, comprises five buildings.
In December, it was failed for the second time in 2017 on all eight standards inspected.
Inspectors became seriously concerned about the nutritional and fluid intake of four residents whose records they reviewed.
They showed that one, who was fed through a transgastric tube, had not received the recommended 1,600 millilitres of fluid and nutritional feed on at least four days.
In one of these 24-hour periods, only 30ml were reported to have been administered, less than 2% of the recommended volume.
Three other residents were recorded as having received "unsatisfactory" daily fluids and food.
The report states that the total recorded daily intake of one person was a small yoghurt and an average sized portion of breakfast cereal in the morning and shepherds pie with vegetables and an glass of orange squash in the afternoon.
One resident had not had dietetic inputs into his/her care for nine months, despite a recommendation of three-monthly reviews.
Another had had no such input for eight months, despite a recommendation of two-monthly reviews.
The report states that inspectors sought immediate written assurances from Stewarts Care about their concerns regarding dietary provision.
Inspectors also found that, in the five months since the previous inspection, the facility had failed to provide a safe service to residents and to protect them from abuse.
They identified six incidents of abuse which had not been appropriately followed up in line with the HSE's procedures for Safeguarding Vulnerable Persons at Risk (issued in 2014).
Three of the incidents related to peer-to-peer abuse, while the remaining three involved to unexplained injuries to residents.
Other failures identified related to the centre's overall governance and management, health and safety and risk management and fire protection.
Almost two-thirds (63.5%) of staff had not to have participated in a fire drill.
Red flags were also raised about the use of institutionalised practices, medication management, and inappropriate staffing numbers to meet the assessed need of residents.
Following last summer's threat by HIQA to move to have the centre deregistered in the courts, Stewarts Care gave assurances to the regulator.
The report says these formed a core element of December's inspection, but that 19 of the 28 actions in Stewarts Care's summer submission were found not to have been satisfactorily implemented.
HIQA says that, since December, it has required the provider to implement a six-month governance improvement plan which it says is being monitored closely to verify whether the charity's actions are leading to improvements in residents' safety and quality of life.
The Board of Stewarts Care said today's HIQA report, and previous critical findings by the watchdog, reflect the extreme challenges the charity faces in delivering change in a resource constrained environment.
In a statement, the charity said it needs support from the HSE and other stakeholders if it is to secure the capital and human resource investment required to overcome the issues raised by reviews it has commissioned, as well as by HIQA inspections.
The board said it fully accepts that the conditions described in the reports are unacceptable, that governance and management systems were not effective and that the standards on risk assessment and safeguarding - including the condition of the physical environment - clearly did not meet the standards of care its members expect of themselves.
It said reforms had been initiated which will ensure that no more than four residents will share a home and no resident will share a bedroom.
The board said it is accelerating the previously planned break-up of the congregated residential setting in which Stewarts Care services had been provided and is "transitioning" all residents into community settings.
The statement underlines that the programme is being managed under the terms of a governance improvement plan agreed with HIQA.
It adds that the plan's implementation is subject to monthly reporting to HIQA with a particular focus on safety and quality of life.
In a background note, the board said the charity previously provided care for 260 residents through 6 Persons in Charge at 15 centres.
But it added, that a new structure is now being put in place involving 29 Persons in Charge and 29 centres, each with its own staffing and dedicated governance and management structures.