Hiqa finds major medicine mismanagement in care centre

A centre which withdrew respite care from the family of a former carer of the year was found to have a high level of medication management failings, as revealed by health watchdog Hiqa.

Two inspection reports into St Laurence’s, run by The Cheshire Foundation in Ireland, found there was a number of medication- related incidents — some of which were categorised as “near misses”.

It was one of five centres around the country run by Cheshire which were inspected by the Health Information and Quality Authority (Hiqa).

Last month, the Irish Examiner reported the family of Sinéad McDonnell had learned in December that its longstanding respite arrangement with St Laurence’s had been pulled.

Sinéad’s mother, 78-year-old Mary McDonnell, from Douglas in Cork, claimed she suffered a “100% cut to my respite” and appealed for an alternative arrangement to be found for her daughter. A number of other families were similarly affected by the decision to cut respite services at the facility.

The first Hiqa inspection report found numerous areas of good practice but also issues over medication-related incidents. Since the previous inspection, a total of 39 medication-related incidents had been reported, six of which were “near miss” events.

According to Hiqa, reporting forms indicated similar incidents were being repeated and there had been evidence of medicines, including antibiotics, being omitted while some medication-related incidents were not reported and preventative actions were not always outlined or were inadequate.

The second report outlined how medicines management audits had not been completed since the previous inspection and, how following a review of a sample of medication prescription and administration records, “it could not be demonstrated that medicines were always administered as prescribed due to ambiguous, unclear or inadequate documentation”.

Other issues included medicines not administered as prescribed on 11 occasions, including six occasions where the dose of a medicine was missed, two occasions where a medicine was administered at a frequency greater than prescribed; one occasion where a dose higher than prescribed was administered, one occasion where a medicine was administered a time different to that prescribed and one occasion where a medicine was administered that had been previously stopped by the prescriber.

A separate report into a Cheshire centre in Tullow in Co Carlow, found there were a number of incidents that had not been notified to the authority in accordance with legislation. These included a resident admitted with pressure sores and resident going missing.

There were also concerns over personal alarms and fire safety issues, the management of residents’ finances and planned night-time staffing levels.

• www.hiqa.ie