National Preventive Mechanism floor mats, body pressure sensors, microchips) and low-profile beds in order to minimise the risk of falling and the consequences of injury. The supervisory authority stated that it would be desirable to have more staff work on night shifts. However, because the minimum staffing ratio had already been exceeded, there was no legal basis requiring more staff. Massive conflicts and complaints following staff changes In a nursing home in Carinthia, in 2015 Commission 3 found serious deficiencies. During the follow-up visit in July 2016, both staff and residents and their relatives addressed the experts with calls for help. Within the space of eight months all qualified staff, including the head of the nursing staff, had left the facility. Although newly appointed staff appeared to be motivated, they did not receive any induction training and there was no team spirit. Out of the original 25 doctors, only four were willing to attend patients in the nursing home. Various residents described to the Commission how much they were suffering from the poor care situation. The regional government of Carinthia informed the NPM that more than ten supervisory examinations in situ were carried out during the reporting year. As required action had not been taken in a timely manner by the facility, the supervisory authority ordered that it be carried out by a third party. At the cost of the operator of the facility, the authority commissioned qualified staff from a mobile service to monitor nursing documentation and for the administration of medication. No entries in nursing documentation for months In a nursing home in Burgenland the nursing documentation was so incomplete and inadequate that no entries were made for months. For instance, it was not always apparent to Commission 6 which medication was given to whom. Staff reported to the Commission that they had not received sufficient training concerning the documentation system. The lack of a quality management system on management level not only resulted in impermissible restrictions of freedom – as they were not reported to the representatives of the residents – and some mistakes in the administration of medication, but also to further serious violations of nursing standards: care planning did not take account of increased risks of falls, and regular pain assessments were not carried out. Team conflicts endanger residents Also unresolved conflicts within teams can lead to a situation in which responsibilities are not taken and residents are neglected. Commission 1 became aware of a situation in Tyrol in which disputes between staff had the result that incontinent residents, who were no longer cleaned by the day shift before going to bed and provided with fresh incontinence products, were also ignored by the night shift. Leaving the skin of elderly persons, which is already weakened by age, in contact with urine and faeces leads to painful skin conditions and pressure sores. One nurse was dismissed as a result. Conflicts between residents Managers and nursing staff must also take care if conflicts occur between residents; in particular, the possibility for individual privacy should also be offered. There was, for instance, a case involving a deadly attack on a fellow resident by an 88-year-old who couldn’t fall asleep because of occasional cries. 106