documented with all of the relevant information. This includes always informing the person that they can withdraw their declaration of consent at any time. Furthermore, persons who have made such a declaration should be asked at regular intervals (e.g. every three months) whether their declaration still applies. This response should be documented, dated and signed by the resident to confirm the validity of the declaration. Facilities should ensure that these measures are implemented and establish appropriate procedures. resident by mixing it with their food. For many of these pills, the manufacturer’s instructions stated that the medicine should not be crushed. Furthermore, the mixing of medicine into food contravenes basic medical rules on the administration of medicine. Medicines are chemically active substances which interfere with the physiological processes of an organism. When administered incorrectly, the intended effect can be altered and the health of the person concerned may be at risk. Facilities must respect the rights of residents to the protection of their physical and mental integrity, and ensure that the applicable rules and regulations are adhered to in the administration of medicine. 3.2.3 – Restrictions of independence The main exit door in one facility was covered by an adhesive foil print, making it hard to identify. The door itself was not locked, and a sign labelled “exit” was fitted above the door. Elements which might potentially confuse residents represent a violation of their rights of personality. Furthermore, the services provided by long-term care insurance must be such that persons in need of care are able to lead an independent and self-determined 63 life to the greatest possible extent. This also includes establishing conditions which help residents’ orientation. Facilities must take this requirement into account. 3.2.6 – Emergency calls In two facilities, residents were either unable to reach the emergency call system or were limited in their ability to do so. In one case, the bell cord had been torn off, making it impossible to trigger an emergency call. In another case, residents in the care unit for dementia sufferers were not given an extension cable in their rooms so they could access the emergency call bell above their beds. As a result, it is not always possible for them to reach the emergency call bell. This is particularly true when the residents are in their room but not in their bed. Checks were carried out every 1-2 hours. Residents must always be able to attract the attention of staff and request assistance. It must be ensured that the emergency call system is always reachable and in working order. 3.2.4 – Health care guardianship In three of the visited facilities, the National Agency found that guardians responsible for health care were not involved to the extent their role requires. A guardian is appointed to actively represent the interests of the person under guardianship towards third parties in accordance with their assigned area of responsibility. This applies equally to authorised representatives with the same responsibilities. It is therefore necessary that legal representatives are comprehensively informed in advance of the intention behind any changes in treatment or medication to be made by the attending physician (including reasoning, potential effects and alternatives) and that representatives make an informed decision on this basis regarding the intended changes. Facilities must establish suitable workflows to ensure this is the case. 3.2.7 – Fire protection One of the visited facilities had no fire protection concept. Furthermore, the smoke detections were out of order and emergency exits were not always kept clear. Facilities must ensure an appropriate level of fire protection for residents. 3.2.8 – Protection against infection The National Agency criticised two facilities for the degree of protection they provided against infection. In one facility it was found that caregivers did not wear protective clothing even when it was evidently necessary to do so. In another facility, the National Agency noted that a large number of residents were 64 carrying MRSA . This was said to have been caused by a previous hospital stay. The effected rooms were labelled accordingly, with material storage stations placed in front of each one so that protective 3.2.5 – Administration of medicine During one visit, the National Agency observed various types of pills being ground together so that the resulting powder could be administered to the 63 Section 2 (1), Book XI, of the German Social Code (SGB XI) concerning social long-term care insurance. 64 47 Strains of methicillin-resistant Staphylococcus aureus.