A damning report into a Dublin facility for people with disabilities suggests some residents were not consulted about do not resuscitate orders.
An unannounced inspection by Hiqa of Cherry Orchard Hospital in January this year, just two months after it had threatened to close the centre down, has detailed a litany of major non-compliances.
14 non-compliances in 18 areas were highlighted, ten of which were major.
They include listing "going to bed" as community inclusion and attending a physio appointment as an "activity".
Inspectors were not happy that action had been taken to address potential financial abuse.
There was not a paper trail to show that residents or their families were aware they had been identified as not to be resuscitated.
Hiqa acknowledged some measures were being taken to address certain failures - but these were at too early a stage in January to have brought about positive change.
Sarah Lennon from Inclusion Ireland says the health watchdog has uncovered issues that are literally life and death.
"A person can, I suppose, at any time refuse medical treatment and put in place a do not resuscitate order, which says 'if I had a heart attack I don't want my heart to be restarted'," she said.
"If somebody doesn't have the capacity or the ability to make that decision, it's actually then a decision that would need to go to the courts.
"It's not actually allowed for another adult to make a decision that serious for another adult."