The Public Defender of Rights

Protection of Persons Restricted in their Freedom

Social Care Institutions

Visits and activities in 2013

In performing systematic visits, the Defender mostly focused on residential social service facilities providing care to elderly people suffering from the dementia syndrome. An inquiry was also conducted at one non-registered facility. The Defender found maltreatment in seven cases. The following facilities were visited (chronologically, from the beginning of 2013): Domov pro seniory Třebíč, Domov Slaný, Alzheimercentrum Průhonice, o. p. s. (Prague), Charitní dům pokojného stáří Cetechovice, Domov pro seniory Světlo (Drhovle), Domov pro seniory Uničov, s. r. o., Domov pro seniory Kobylisy (Prague), Domov pro seniory Pyšely, Dům seniorů Liberec – Františkov, TOREAL, spol. s r. o. (Královské Poříčí), Domov u zámku, o. s. (Chvalkovice na Hané), Lázně Letiny, s. r. o., Domov pro seniory Pampeliška (Česká Lípa), Domov pro seniory Zlaté slunce (Ostrava) and Centrum komplexních služeb pro rodinu a domácnost Kunštát.

During the visits, the examined areas included particularly the environment and equipment of facilities, whether the principle of the freedom to arrange one’s own affairs was respected and the privacy of clients ensured, the clients’ freedom of movement and their safety, the quality of the provided social services and nursing care, or the conditions of concluding a contract for the provision of social services and its contents. In all of the mentioned areas, the central theme was the protection of human dignity and the protection of (not only) fundamental rights and freedoms of clients.

The most frequent shortcoming encountered during the examination of material conditions consisted in the failure to adjust the environment to the needs of clients with dementia. Such persons may be disoriented and may easily get lost even in familiar places. Therefore, the area where they move around should be well organised and support spatial orientation (e.g. the use of different colours marking each floor, pictograms on room doors, orientation signs in halls and so on). One of the issues that the Defender criticized in some cases was the absence of communal dining rooms or common areas. Regular communal dining has crucial socialization importance and clients with dementia may significantly profit from it depending on the stage of the illness (it improves the quality of the life of clients, forms a part of the daily programme, helps to maintain self-reliance).

In the area of ensuring privacy, the Defender was particularly interested in whether the privacy of clients in toilets, during the maintenance of hygiene or the provision of nursing care was respected, whether in a bathroom, on a bed in a room or in the nurse’s room. He recommended that no one be exposed to being seen by other clients and that the relevant acts be performed behind closed doors or a screen. He also criticised, where relevant, the impossibility of clients to store safely their belongings. Although the Defender is aware that not all clients suffering from dementia are able to use keys to lockers or drawers, he recommended that those able to do so have a lockable space in their room and that conditions for the storage of belongings to protect them against theft be created for all.

While checking if the clients’ freedom of movement was ensured, the Defender examined especially the use of restraining means within Sec. 89 of the Social Services Act (Act No. 108/2006 Coll., as amended). Unlawful administration of sedatives was a frequent shortcoming. The Defender found that physicians often prescribed irregular administration of sedatives in case of agitation or aggression. Nevertheless, the prescriptions are so vague that in practice it is not a physician who decides on the administration of a sedative but an employee of the facility (in some cases not even a medical officer). The facility does not regard the administration of sedatives as the use of restraining means even if the purpose of the administration of such medication in a specific case is to restrain a client (prevent him or her from walking, getting up, or due to aggressive behaviour). In a number of cases, no records about the administration of a sedative were maintained; the existing records gave rise to doubts as to whether the statutory conditions for the administration of a sedative as a means of restraint had been met and in several cases evidence about procedure in violation of the statutory prohibition of restraining movement was obtained.

As regards the quality of the care provided, in all of the facilities the Defender concentrated primarily on proper nutrition of clients. In particular clients whose communication ability is limited or who are permanently confined to bed have to depend completely on the care provided by the staff, which must include the provision of nutrition. The underestimation of the risk of malnutrition and its insufficient prevention was the most serious shortcoming in this area. In a number of facilities, nutrition screening is not performed, clients are not regularly weighed, food intake is not systematically monitored and facilities do not cooperate with a nutritional therapist. Clients suffering from the dementia syndrome belong to a risk group as regards the occurrence of malnutrition and some are completely dependent for nutrition on the care of the facility staff. The modification of food texture is a related problem. The Defender objected to cases where all food components were blended together during the mechanical modification of food texture (blending), which in the end looked very unappealing and unappetizing, preventing clients to enjoy their meals in any way. The Defender also focused on the manner of preparing and administering medication to clients. He criticized situations where medication was prepared according to medication lists, with changes and cross-outs made by the staff, and the correctness of the prescription could not be verified. Further, the Defender pointed out that medication was not stored in a safe place and could be also reached by persons who were not authorised to handle it. In most of the facilities visited, micturition regime (determination of the form and frequency of assisting clients to use the toilet) was not determined for clients suffering from dementia and in several cases the onset of complete incontinence was even accelerated. In most facilities, depression was not systematically checked for or monitored and standardised monitoring of pain did not take place. Finally, the Defender criticised the impossibility to establish from the fi les how long the patient permanently confined to bed had not been getting up, who had decided on the patient’s further confinement to bed on an all-day basis and on what grounds. Permanent confinement to bed constitutes crucial and often irreversible deterioration in the quality of life and therefore it should be discussed by a physician and duly recorded in the client’s files.

In the area of ensuring the safety of clients, the Defender found most shortcomings in the incorrect use of sideboards. Even though employees of facilities were aware that a sideboard could restrain the client’s movement, they were not concerned with the purpose of its use if the client’s guardian or relative had given consent to its use. The Defender repeatedly explained that the use of a sideboard was right if its purpose was to protect the client from fall after other less restrictive preventive measures had been tried out without success or their use had been excluded beforehand for a justified cause. In such a case sideboards are a standard nursing instrument and the consent of third persons is without legal significance. However, the use of sideboards for the purpose of restraining the client’s movement is undesirable and it cannot be made good by potential consent. Insufficient prevention of falls was another frequent shortcoming. Falls may have very serious consequences for elderly people (e.g. fractures, head injuries, anxiety, depressions and so on). The Defender criticised the absence of a systematic fall risk assessment, the absence of a proper analysis of the causes, the absence of preventive measures and of transparent statistics of falls.

The Defender also obtained findings about the shortage of funds in the given area of social services, although that was not the purpose of the visits. Social services are funded from multiple sources and subsidies from the State budget remain an important source for the providers. The size of subsidies earmarked for this area is stagnating or declining. Providers of social services are thus forced to reduce the working hours of professional medical staff; and headcount reduction also concerns direct care workers. This situation affects the quality of the provided care and negatively impacts the life of clients in the facilities. In some cases the facilities consequently cannot comply with the quality standards of care for this specific target group of clients. For example, in one facility the Defender recommended on-site presence of a head nurse on a daily basis and he acknowledged the care for clients provided by a sufficient number of direct care workers. The facility subsequently informed the Defender that it was forced to reduce the working hours of the medical staff and lay off more direct care workers.

Generalized findings, related recommendations and systemic evaluation will be published by the Defender in a summary report in 2014. In 2013 he already prepared and published partial outputs for practical use, such as “Extracts from reports on visits to facilities for elderly people” or a paper on the problems in ensuring the nutrition of elderly people.

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