An independent report into the running of the new adult mental health unit at UHG has raised concerns about physical restraints being used on patients, as well as the use of seclusion and delays in informing GPs of discharges.
Two patients were not told why they were being restrained or for how long, and there was no record to indicate if they had been medically examined within three hours of being restrained.
‘High risk’ failings were also recorded relating to the discharge of a patient – their GP was not given a discharge summary within the required three days and full information was not sent to relevant personnel for 23 days, rather than within the required 14-day timeframe.
During an inspection of the 50-bed Acute Adult Mental Health Unit (AAMHU) by the Mental Health Commission – the independent watchdog which oversees standards and practices – two patients had not been told why they were being physically restrained or how long the restraints would be used for.
The unannounced inspection was carried out at the €20 million UHG unit from November 27th to 30th last and the Commission published its findings last week.
Areas of inspection were deemed to be either compliant or non-compliant – where non-compliant, risk is rated as low, moderate, high or critical.
High-risk non-compliance was recorded in four areas: The Code of Practice on the use of physical restraint; the Code of Practice on admission, transfer and discharge and on regulations relating to staffing and the register of residents.
Dr Susan Finnerty of the Mental Health Commission said in her report that the inspection had looked at the clinical files of three residents who had been physically restrained.
“In two episodes of physical restraint, there was no record to indicate that the resident had received a medical exam at all by a registered medical practitioner within three hours after the start of an episode of physical restraint.
“In one case, while a medical exam did take place, there was no time record to show that it took place within three hours after the start of the physical restraint episodes.
“In two physical restraint episodes, residents were not informed of the reasons for, duration of, and circumstances leading to discontinuation of physical restraint. The reasons for not informing them was not documented in either case.
“In [each of] two episodes of physical restraint the residents’ next-of-kin was not informed about the physical restraint and the reasons for not informing them was not documented in two cases,
“In all three physical restraint episodes, there was no documented record to indicate that each episode of physical restraint was reviewed by members of the multi-disciplinary team and documented in the clinical file within two working days after the episode.”
The report also noted that: “In all cases, physical restraint was initiated by an appropriately qualified health professional. Physical restraint was used in rare and exceptional circumstances only when the resident posed an immediate threat of serious harm to themselves or others. Cultural awareness and gender sensitivity were demonstrated when considering the use of and when using physical restraint.”
The MHC’s report also found that not all staff had signed a log to indicate they had read and understood the policy in relation to using physical restraints.
In its response, the HSE said its corrective action would include a training schedule for medical staff and a checklist to be completed ‘post restraint’ to ensure regulations were met.
The inspection noted ‘high risk’ non-compliance in terms of regulations on staffing, which was due to the fact that not all staff had up-to-date mandatory training in basic life support; fire safety; management of violence and aggression and in the Mental Health Act. The HSE responded that training needs would be assessed and staff would complete mandatory training. The unit was also non-compliant (high-risk) with the Code of Practice on admission, transfer and discharge – one resident’s discharge plan did not include documented communication with the GP.
The preliminary discharge summary was not sent to the patient’s GP within three days and comprehensive discharge summaries were not sent to relevant personnel within the required timeframe of 14 days – instead, it was 23 days after the resident had been discharged.
Discharge summaries did not include details of prognosis and a follow-up appointment was not arranged within one week of discharge.
A memo has since been sent to all staff to ensure the discharge plan for patients complies with regulations, and a new ‘initial discharge book’ is being developed to send to GPs on the day of discharge.
‘High risk’ non-compliance was also noted for regulations governing the register of residents, which was found not to be up-to-date, while residents’ names were not consistently recorded. The HSE said a new computerised database was being developed to keep all information and staff have been reminded to input all data.
‘Moderate risk’ non-compliance with rules governing the use of seclusion was also recorded.
“In two seclusion episodes, the resident was not informed of the reasons, duration, and circumstances leading to discontinuation of seclusion. In two seclusion episodes, the resident was not informed of the ending of an episode of seclusion, and in one seclusion episode, the reason for ending seclusion was not recorded in the clinical file.” The HSE said a training schedule would be arranged for staff and a checklist for when seclusion of a patient is discontinued.
The ’moderate risk’ non-compliance for use of CCTV relates to the equipment being capable of recording the image of a resident who was under observation. According to the HSE, the system is no longer capable of recorded and this is checked monthly.
The Commission’s report found ‘low risk’ non-compliance with regulations on maintenance of records – these contained loose pages and notes were out of logical sequence, while one resident’s record contained multiple different dates of admission. The HSE said a memo was sent to all staff to file notes in keeping with regulations and audits of records would be undertaken every three months.
Overall, the inspection found the centre was compliant with 81% of regulations, rules and codes of practice.
Areas of compliance with regulations which were rated as ‘excellent’ included the identification of residents; food and nutrition; food safety; clothing; residents’ personal property; religion; communication and searches of patients and their belongings.