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A Report by the Ombudsman in relation to a complaint about the care and treatment of a patient at St Mary's Care Centre, Mulingar, Co Westmeath

Appendix B - HSE's Action Plan

Action Plan in response to recommendations from the Ombudsman's investigation Report (July 2008) on a complaint by Mrs Jane Moore against the HSE.

Health Service Executive (HSE) Action Plan
  Ombudsman's Recommendations relating to St Mary's Care Centre, Mullingar Co Westmeath (in conjunction with HSE Dublin Mid-Leinster)   HSE's planned Actions in response to Ombudsman's Recommendations   Date to be completed    Lead Person
1   Develop written protocols with regard to the referral of patients (both respite and long-stay patients) for all para-medical services, including speech and language therapy assessments. These protocols should be understood and implemented by all members of staff, including medical staff, and new or temporary staff in the Centre, and should provide for urgent referrals when regular para-medical staff members are unavailable.

(a) The draft Standard Operating System Procedures (SOPS) for speech & Language Therapy referrals will be reviewed and amended as required. The policy in this regard will incorporate consideration of the needs of short stay residents.

(b) A specific policy on Dysphagia will be developed which will include protocols for referrals to the appropriate therapy staff re the prioritisation of such referrals. 
(c) The referral systems for all relevant allied health professionals will also be reviewed and amended, as appropriate

All by 31st October 2008

 (a) Speech and Language Therapy Manager
(b) Speech and Language Therapy Manager, Director of Nursing, Medical Officer
(c) Service Managers - Occupational Therapy Manager - Physiotherapy Manager- Speech and Language Therapy Manager 
 2 Provide ongoing education and training programmes for all staff members to ensure that they communicate effectively with each other, with the elderly residents, and their families.

(a) Regular Team Meetings will continue to take place in the Care Centre.

(b) The Person-Centred Care Project which addresses the various elements of communication processes (i.e. inter staff, between staff and residents, between staff and families) will continue
(c) The induction and on-going training of staff will be reviewed with specific focus on consumer affairs and raising awareness about policies and procedures consistent with national standards/guidelines
(d) Linkages with HSE Consumer Affairs Office for the purposes of training will be further developed
(e) The system of dissemination of new Policies, Procedures and Guidelines will be reviewed.
(f) Systems of communication with families, including but not limited to, identification of agreed family representatives, will be reviewed.
(g) Staff will be actively involved in the development of new or revised policies/protocols at the Care Centre.
(h) The terms of reference of Residents Groups will be reviewed
(i) Specific training events will be organised to upskill staff in the following areas of communications and client care:-

  • Complaints management
  • Tissue Viability
  • Dysphagia
  • Medication Administration including the crushing of medications 
 (a) to (h) All by 31st October 2008
(i) December 2008 subject to availability of trainers

(c) Director of Nursing Service Managers, Local Health Manager, Area Manager for Consumer Affairs

(d) Local Health Manager
(e) Director of Nursing, Service Managers

(f) Director of Nursing, Service Managers
(g) Director of Nursing, Service Managers
(h) Director of Nursing, Area Manager for Consumer Affairs
(i) Director of Nursing, Speech and Language Therapy Manager, Occupational Therapy Manager, Area Manager for Consumer Affairs

 3  Revise and develop protocols for the admission of a person for respite care, particularly if it is a first respite admission, to ensure that all of the patient's needs are identified, and provided for in a timely manner. Consideration might be also be given to meeting with the patient's carer/s in advance, and having the patient examined by the Medical Officer on day of admission;

 (a) Respite Care Policy will be reviewed to include examination/development of the following:-

  • Pre-admission criteria and protocols.
  • Duties/responsibilities of referrers.
  • Advance information required by Care Centre and the appropriate timescale to be agreed with the Centre prior to the patient's admission. 
  • Visit by relevant staff, if feasible, to first referral applicants at their home prior to admission for respite care.
  • Protocol for recording of information at every stage of the care continuum.
  • Medication policy for respite patients (in conjunction with general medication policy)
  • Assessment care planning and care plan review for respite patients.

(b) An assessment tool will be identified to assist with assessing patient needs on admission.
(c) The assessment/referral form which is currently in use will be reviewed and updated, as necessary, as part of the overall review process
(d) the Liaison Public Health Nurse will continue to attend weekly multi-disciplinary team meetings where new referrals, both long stay and respite care patients, are discussed and prioritised and specific patient needs are highlighted.  		 All by 31st October 2008 Director of Nursing, Risk Manager, Director of Public Health Nursing, Medical Officer, Service Managers
 4  Revise protocols for nursing staff to reflect best practice with regard to the turning of patients who are susceptible to developing pressure sores;

 Tissue Viability Policy will be reviewed/further developed incorporating the following:-

  • Protocols for assessment of tissue viability.
  • Identification of indicators of risk.
  • Treatment of pressure ulcers.
  • Protocols for seeking expert advice.
  • Continuous up-skilling of staff in current international best practice.
 31st October 2008

Director of Nursing

Occupational Therapy Manager

 5  Develop protocols for nursing staff with regard to the seeking of advice from the Director of Nursing on crisis intervention, and develop a policy regarding the transfer of residents to acute hospital services;

 (a) Written guidelines for transfer of patients to acute hospital services will be developed.

(b) Clinical Nurse Managers/Nurse In Charge will continue to consult with Director of Nursing on a daily basis, as required.

(c) 24-hour telephone support will continue to be provided by the Director of Nursing.

(d) Structured Clinical Nurse Manager meetings will continue to take place.

(e) Weekly Multidisciplinary Team meetings will also continue which provide a forum for discussing individual patient issues.

(f) 24-hour medical support will continue to be provided by a designated Medical Officer and an Out of Hours Medical Service.
(g) In the event of an emergency, patients will continue to be transferred to the acute hospital which is in close proximity to the Elderly Care Centre. A standardised transfer form between the Elderly Care Centre and the Acute Hospital has been developed and is operational 

 31st December 2008

Director of Nursing- Elderly Care Centre

Director of Nursing - Acute Hospital

General Manager 

 6  Provide education and training for all nursing staff in caring for residents who may be unable to communicate their own needs;  (a) Training of staff in communicating with patients with dementia, which has already been undertaken by a number of staff, will continue.
(b) FETAC training, which also promotes effective communication with staff, residents and relatives, and which has also been undertaken by a number of staff, will continue.
(c) The availability of further appropriate training will be reviewed in the context of availability of resources.
(d) Development of in-house training programmes will be explored.		 31st October 2008 Director of Nursing
 7  Arrange for Nursing staff to ensure that the wishes of residents and their relatives are documented, listened to and acted upon, and that carers/relatives are kept fully informed with regard to their relatives' condition. If any difficulties arise with regard to the management of any patient, their principal carer or next of kin should be immediately advised;

 (a) In-house training on the HSE National Complaints policy will be arranged.

(b) See also Items 2 and 6 above.

 31st December 2008 - subject to availability of trainers Director of Nursing, Area Manager for Consumer Affairs
 8  Record difficulties with regard to the administration of medication to patients in the nursing records and on the prescription sheet, and these records should accurately reflect the amount of medication administered and consumed;

(a) A revised drug prescription chart which has been implemented will be reviewed on a three-monthly basis.

(b) All prescribed medications administered will continue to be recorded by qualified nursing staff. In cases where medication cannot be administered, this fact and the reasons for non-administration will also continue to be recorded.
(c) Existing policy will be reviewed and revised as necessary regarding:-

  • Supply of medications for respite patients.
  • Storage of respite patients' medication.
  • Policy on use of resident's own stock of medication.
  • Crushing of medication - as outlined in Standard 15 of the new National Residential Care Standards.
 31st October 2008

(a) (b) Director of Nursing, Chief Pharmacist for Acute Hospital 

(c) Director of Nursing, Medical Officer, Local Health Manager, Chief Pharmacist for Acute Hospital

Nursing Midwifery Planning and Development Unit

 9  Review its procedures to ensure that all significant observations on a patient's condition are recorded in the nursing records, and that entries accurately reflect the interaction between nurse and patient, and include important interactions with his/her carer or relative;

 (a) Individual Care Plans will continue to be audited on an on-going basis.

(b) The recording of observations, which is an integral part of this process, will also continue.

(c) Training will continue to be provided to all nursing staff regarding these Care Plans.

(d) The Documentation Liaison staff member will continue to feed back to the Regional Documentation Group.

(e) Care Plan documentation will be reviewed to maximise effectiveness.

(f) Care Plan Policy for respite patients will be developed to include:-

  • Inclusion of patients and relatives in the process.
  • Identification of an assessment tool to be used for each respite patient on admission.
  • Accurate documentation in the written records of every stage of the process exactly demonstrating practice.
  • Care Plan Reviews which must take place at regular intervals and especially when there is a changes in the health status of the patient.
  • Protocol for inclusion of the Medical Officer in assessment and review process.

 31 December 2008

(a) (b) (c) (d) (e) Director of Nursing, Nursing Midwifery Planning and Development Unit

(f) Director of Nursing, Nursing Midwifery Planning and Development Unit, Medical Officer

10   The General Manager should review the complaints handling process to ensure that complainants are kept fully informed and updated as to the status of their complaint, and to ensure that there is a system in place which will ensure proper engagement between a complainant and HSE staff.

 (a) The HSE National Complaints Policy which sets out statutory requirements in relation to acknowledgement, investigation, and response to complaints will continue to be implemented.

(b) The implementation of this policy will be reviewed to ensure that the following are in force:-
  • Protocols for front-line staff to deal with complaints in the first instance.
  • Appropriate timescales with respect to communication with complainants while an investigation is in progress.
  • Named person to take overall responsibility for managing the process.

( c)  Further review  of training needs on HSE National Complaints Policy will be undertaken.

(d) Further linkages with the HSE Consumer Affairs Office for the purpose of training staff in consumer focus will be developed.

 31st October 2008 Director of Nursing, Service Managers, Local Health Manager, General Manager, Area Manager for Consumer Affairs.
 Ombudsman's Recommendations relating to the Health Service Executive (HSE)   HSE's planned Actions in response to Ombudsman's Recommendations  Date to be completed Lead Person
 1 (The HSE) Should explore with the relevant stakeholders the possibility of introducing guidelines for Medical Officers with regard to the supply of medication for patients who are leaving hospital or nursing home care, to ensure continuity of care until they can arrange to be seen by their own GP. This matter will be examined further in association with appropriate medical professionals. The HSE will revert to the Ombudsman with its response in this regard when the examination is complete  30 November 2008 Principal Area Medical Officer
 2 That the HSE - Dublin Mid-Leinster makes a "Time and Trouble" payment of €3000 to Mrs Moore in recognition of the effort expended by her in the pursuit of her complaint.  This matter will be dealt with by the appropriate offices within the HSE  31 October 2008 LHM
Medical Nursing Issues HSE Response Dated to be completed  Lead Person
1

Syringe Feeding of Patients

Ref: Page 20 of Investigation Report

 This matter will be examined further in association with the appropriate medical professionals. The HSE will revert to the Ombudsman with its response in this regard when this examination process is complete. 30 November 2008 Principal Area Medical Officer
2

Crushing of Tablets - in particular Nu-Seals Aspirin

Ref. Page 30 of Investigation Report

  This matter will be examined further in association with the appropriate medical professionals. The HSE will revert to the Ombudsman with its response in this regard when this examination process is complete. 30 November 2008  Principal Area Medical Officer
3

Non-provision of medication by the Medical Officer to Mrs Moore for Mrs Kelly (RIP) on Mrs Kelly being taken home against the medical advice of the Medical Officer

Ref: Page 32 of Investigation Report

  This matter will be examined further in association with the appropriate medical professionals. The HSE will revert to the Ombudsman with its response in this regard when this examination process is complete. 30 November 2008  Principal Area Medical Officer

 

                                                               

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