Staff at a Co Clare nursing home were unable to account for potent psychotropic drugs which went missing, according to a report from the Health Information and Quality Authority (Hiqa).
Inspectors highlighted worries regarding medication-management procedures at Athlunkard House Nursing Home near Limerick city, and expressed "significant concern" heavy sedatives for elderly patients were unaccounted for in the dosage system.
“There was a lack of documentation to account for the administration of a significant number of . . . psychotropic medications,” read the report, which also highlighted discrepancies between prescription sheets and medication administration sheets.
Dosage system
“Where medications were missing from the monitored dosage system, many were not accounted for in residents’ medication administration sheets. Nursing staff spoken with were unable to account for when or to whom these medications were administered to.”
Psychotropic medication should only be used as a last resort in nursing homes according to healthcare experts, but is often relied upon to control disruptive or challenging behaviour in elderly patients.
Discontinued drugs
The report went on to state that medications no longer in use in the home, including rectal diazepam, haloperidol injection and lithium tablets, continued to be stored on medication trolleys or in presses.
There was no procedure for returning disused medications to the pharmacy, which led to the unnecessary accumulation of prescriptions.
Some products including sleeping tablets and painkillers were stored without prescription labels, tablets were sometimes missing from boxes, and a medicinal product which should have been kept in a fridge was put on the medication trolley.
An immediate action plan was issued following the findings, and was responded to in a “timely and comprehensive manner” according to Hiqa.
Inspectors criticised “inadequate governance arrangements” in the home, which complied with three of 11 standards tested during an unannounced visit on April 21st.