High-risk issues on patient records, physical restraint at Letterkenny mental health unit

Significant risks have been found at the Department of Psychiatry at Letterkenny University Hospital in relation to the maintenance of records.

An inspection of the facility found that patient records were mixed up while in another instance one patient's records were not located in a “logical sequence”.

One patient's risk assessment was found to be filed with another patient's clinical file and another resident's documented diagnosis did not match other clinical notes related to that person.

“This posed a risk to individual residents during the delivery of individualised care,” a report by the Mental Health Commission highlighted.

“Not all components of the approved centre’s comprehensive risk management policy was implemented in practice.

“Clinical risks were not managed adequately. “This related to a clinical risk firstly, posed by incorrect filing of pages of a current individual care plan within an inactive clinical file, and secondly, posed by incorrect filing of a resident's risk assessment within another resident’s clinical file.”

The inspection, carried out over a four-day period last August found deficits in individual care plans with five not identify proper goals, one not a composite set of documents, one found not to have been reviewed weekly and a further five not updated following review, as indicated by the resident's changing needs, condition, circumstances and goals.

Inspectors found that “not all healthcare staff had completed mandatory training in basic life support, fire safety, and the management of violence and aggression, nor had they completed training in the Mental Health Act 2001.”

The report said: “The Mental Health Act 2001, the associated regulation (S.I. No.551 of 2006), and all other relevant Mental Health Commission documentation were available to staff throughout the approved centre.”

The Department of Psychiatry at LUH is registered for 34 beds and there were 27 residents at the time of inspection.

The facility was non-compliant in nine areas of the inspection.

There were six high risk non-compliances with the regulations on individual care planning, staffing, risk management procedures, the code of practice on the use of physical restraint, with the regulation on the maintenance of records, and with rules governing the use of seclusion.

The report found that the multi-disciplinary team at the facility did not record actions decided upon, nor follow-up plans to eliminate or reduce restrictive interventions in relation to three episodes of physical restraint

An in-person person-centred debrief with the resident who was restrained did not

follow any of the three episodes of physical restraint.

The report said that, “consequently the trigger events which contributed to each of the three separate episodes of restraint were not identified,” that “missed opportunities for earlier intervention were not reviewed” and “alternative de-escalation strategies to be used in future were not identified.”

As a result, staff will now be requested to revisit the policy on the reduction of restrictive practice to refresh on the clear pathways to be followed

The report added: “Appropriate emotional support was not provided to the resident following any of the three episodes of physical restraint, and support was not offered to other individuals who may have witnessed the restraint of the resident in any of the three episodes of physical restraint.”

Inspectors found that there were no adequately sized wardrobes for residents to securely manage their own property. Residents’ property was on the ground in shopping bags and on chairs in a number of bedrooms.

The Department of Psychiatry at Letterkenny University Hospital was found to have 74 per cent overall compliance, down from 78 per cent in 2022.

The centre was not clean everywhere, external walls and windowsills in the courtyard, and external walls in the Acute Assessment Unit were dirty.

There were, however, no identified fire safety concerns, there was an adequate number of trained nursing staff and the ordering, storing, prescription and administration of medication was carried out in a safe manner.

The report found that ligature points were minimised to the lowest level, based on individual risk assessment.

A spokesperson for the MHC said: “The MHC requires corrective and preventive action plans (CAPAs) from all services where non-compliances are identified, each of which must address each non-compliance specifically.

“The MHC monitors the implementation of these CAPAs on an ongoing basis and requests further information and action as necessary.

“Enforcement action is taken when the MHC is concerned that the care and treatment provided in an approved centre may be a risk to the safety, health and well-being of residents, or where there has been a failure by the provider to address an ongoing area of non-compliance.”