1.5 Obiski posebnih socialnovarstvenih zavodov 1.5 Visits to special social care institutions Odmerjanja zdravil po potrebi in priporočila DPM Dosage of medications when needed and the NPM recommendations V zavodu delujejo štirje psihiatri, splošni zdravnik in zobozdravnik, ki skrbijo za medicinsko oskrbo nastanjenih stanovalcev. Zavod vodi redno evidenco naročanja stanovalcev pri psihiatru in splošnem zdravniku. Pri pregledu medicinske dokumentacije je DPM zaznal težavo, ko zdravnik za čas svoje odsotnosti navede, da lahko zavodsko osebje stanovalcu po potrebi da predpisana zdravila. Pri tem je izvedenec ugotovil, da imajo nekateri varovanci predpisano vsakodnevno maksimalne dovoljene odmerke posameznega zdravila in še zdravilo »po potrebi«, kar bi pomenilo, da bi lahko stanovalec na dan prejel zdravila, pri katerih bi bil odmerek višji od maksimalnega priporočenega. DPM je v zvezi s tem predlagal, naj splošni zdravnik in psihiater ponovno pregledata vse primere, kjer je predpisano posamezno zdravilo »po potrebi«. Ob tem naj upoštevata izvedenčeva priporočila, predvsem pa zagotovita, da se spoštujejo maksimalni priporočeni odmerki posameznega zdravila in tako prepreči možnost, da bi prišlo v konkretnem primeru do preseganja (najvišje) meje. Splošna ocena zdravstvene oskrbe stanovalcev zavoda, zlasti na področju psihiatrične oskrbe, je glede na izvedenčevo oceno dobra. V zavodu nimajo čakalnih dob, prav tako dostop do psihiatra traja maksimalno nekaj dni. Tehnična opremljenost je zelo dobra. Four psychiatrists, a general practitioner and a dentist provide medical care for the residents of the institution. The institution keeps a prompt record of residents’ appointments at the psychiatrist and general practitioner. When reviewing the medical documentation, the NPM noted a problem, i.e. during their absence, the physician permits the medical staff to give residents prescribed medications when this is needed. The expert further established that some residents were prescribed maximum daily permitted doses of certain medications and the additional medication “when needed”, which meant that a resident could in one day take medications whose maximum daily permitted dose would exceed the recommended intake. In this regard, the NPM proposed that the general practitioner and the psychiatrist re-examine all cases in which individual medications were prescribed “when needed”, whereby they should observe the expert’s recommendations, and particularly assure that the recommended maximum doses of individual medications be observed, thus preventing the possibility of exceeding (maximum) limits in individual concrete cases. According to the expert, the general evaluation of medical care of the institution’s residents, particularly in the field of psychiatric care, is good. There were no waiting periods in the institution; likewise, the visit to the psychiatrist can be arranged within a few days. Technical equipment is very good. Posebni varovani ukrepi (PVU) in priporočila DPM Osebje v primeru PVU obvesti zdravnika, če je le-ta v zavodu prisoten, da odloči o njegovi uvedbi. Če zdravnik v zavodu ni prisoten, lahko uporabo PVU odredi strokovni delavec, ki takoj obvesti zdravnika in o tem naredi zaznamek. V zaznamku se navede, kateri zdravnik je bil obveščen in tudi, ali je ukrep odobril. DPM je v enem od pregledanih primerov uporabe PVU ugotovil, da je bil ukrep odobren s strani strokovne vodje, čeprav je bil takrat v zavodu prisoten zdravnik. Pri tem je DPM zavodu predlagal, da se pred uvedbo PVU skrbno preveri, ali ni zdravnik morda prisoten, ukrep s strani strokovnega delavca pa se uvede šele ob njegovi odsotnosti. V nadaljevanju je DPM v obiskanem zavodu ponovno ugotovil in ponovil priporočilo iz leta 2011, da predlagamo, da se v evidenco PVU (»Kontrolni list neprekinjenega varovanja bolnika«) vstavi tudi rubrika, kjer bo zabeleženo, kateri zdravnik, katerega dne in ob kateri uri je odobril uporabo PVU, ki ga je uvedel strokovni delavec oziroma delavka. Ob tem je DPM opozoril na izvedenčevo mnenje, da zavod tako zaposlene kot tudi zdravnike, ki PVU odrejajo, posebej opozori, da je PVU skrajni ukrep. Iz dokumentacije pa mora biti vedno razvidno, ali so bili pred uvedbo PVU izvedeni ukrepi in kateri. Prav tako je izvedenec v svojem poročilu predlagal zavodu, da bi bilo treba prilagoditi obrazce, ki se izpolnjujejo ob uvedbi PVU in da se o posameznih PVU ne vodi skupna evidenca v enem dokumentu za več varovancev hkrati. Soba za umiritev in priporočila DPM DPM je ob ogledu nadzorne sobe ugotovil, da se evidence glede opažanj o dogajanju v sobi za umirjanje vodi zelo natančno. Posamezni zapisi o opažanjih si sledijo v nekajminutnih razmakih, kar tudi kaže na stalno navzočnost osebja in neprekinjen nadzor. Kameri v sobi za umirjanje sta delovali brez težav, deloval je tudi prenos zvoka. Le nekaj težav se je pojavilo pri prižiganju enega od monitorjev, saj je bil ta izklopljen iz električne napeljave, daljinskega upravljalnika pa ni bilo ob njem. DPM je pri tem ponovno predlagal priporočilo iz leta 2011, naj zavod redno preverja delovanje vseh potrebnih sklopov za nadzor stanovalca v sobi za umirjanje, torej tudi, če se soba dalj časa ne uporablja. 118 poročilo o izvajanju nalog DPM v letu 2014 DržavnI preventivnI mehanizEm po Opcijskem protokolu h Konvenciji OZN proti mučenju in drugim krutim, nečloveškim ali poniževalnim kaznim ali ravnanju Special protection measures and NPM recommendations The staff inform the physician about special protection measures if the latter is present to order their implementation. If the physician is not present in the institution, the expert worker may order the implementation, and then immediately informs the physician thereof and makes a note. The note also includes the name of the physician informed and whether the measure was approved. In one of the reviewed cases, the NPM discovered that the measure was approved by the expert worker, although a physician was present in the institution at the time. The NPM advised the institution to carefully verify the presence of a physician before the application of special protection measures, and only after the established absence should the measure be approved by the expert worker. The NPM again established and repeated its recommendation from 2011 to include a section in the record of special protection measures (Control list of ongoing protection of a patient) which would state which physician approved the application of special protection measures which were then implemented by an expert worker, and on what day and at what time . On that note, the NPM pointed to the expert’s opinion that the institution should inform the staff, including physicians who order special protection measures, that the special protection measures were the ultimate measure. Furthermore, it had to be evident from the documentation whether other measures had been implemented before the application of special protection measures and what these measures were. In its report, the expert also proposed that the institution amend its forms which were completed upon the implementation of special protection measures and not to keep one joint record on individual special protection measures in one document for several residents. Confinement room and NPM recommendations When reviewing the supervision room, the NPM established that very detailed records were kept about observations of happenings in the confinement room. Individual records of observations were recorded at intervals of several minutes, which pointed to the continuous presence of the staff and uninterrupted supervision. The two cameras in the confinement room worked perfectly and the audio transmission was also functioning. The only problems were with switching on one of the monitors, because it was unplugged and that the remote control was not within reach. The NPM again repeated its recommendation from 2011 that the institution regularly check the functioning of all necessary surveillance systems for monitoring residents in the confinement room, also if the room is not used for long periods. IMPLEMENTATION OF THE DUTIES AND POWERS OF THE NPM IN 2014 National Preventive Mechanism under the Optional Protocol to the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 119