The NPM recommended that the Tolmin Unit improve the system of recording doctor’s instructions, and (again) inform staff on the urgency of obtaining advance approval to change therapy and immediate recording of changes, and to prevent cases of exceeding prescribed therapy by regular control. The management of Podbrdo Retirement Home stated that changes of therapy were always approved by a doctor in advance, which was also recorded, and the staff were informed of this. In the case which was mentioned in the NPM report, the record was insufficient; this was discussed and the staff were notified of the need for consistent record keeping. The NPM recommended that Ribnica Retirement Home inform their psychiatrist that it must be clearly stated whether it is permissible to use both medications when implementing therapy “as needed” in the event of medications (antipsychotics) with combined effects or only one medication in the prescribed quantity. In their reply to the preliminary report, the management explained that such therapy was implemented very rarely. It was used in November three times, whereupon, it was agreed with the psychiatrist and the staff that the first medication was to be used first in the case of medications with combined effects, and if that had no effect, the second medication was to be used. The staff are in constant contact with the psychiatrist. They call her on her mobile phone and promptly inform her about illness symptoms and possible worsening of diseases. The NPM recommended that Ribnica Retirement Home inform their staff about special care when crushing medications, and possibly also agree with the doctor to particularly mark medications which may not be crushed. In their reply to the preliminary report, the management of the home clarified that the staff would particularly carefully mark medications which must not be crushed. The management also claimed that the staff crushed medications only exceptionally. The NPM pointed out to Radenci Retirement Home that prescribing medications “as needed” must be explained in detail, so that staff know when to give such medications to residents and how many times a day the residents may be given such medication (maximum permissible daily dose). We also recommended that limitations recorded for individual medications be copied consistently from the resident’s medical record to other documents where the medication a resident should take or has already taken is recorded or determined. In their reply to the preliminary report, the management of the home stated that the therapy “as needed” is prescribed by the psychiatrist in the medical record. The Loram medication is administered only upon restlessness. The management explained that medication was distributed by experienced medical staff who are familiar with medication, thus avoiding the possibility of administering them for different indications. Medication “as needed” is always prescribed by the psychiatrist in a daily recommended dose, e.g. Loram 2.5 mg Vi tbl pp (means that the maximum daily dose to be administered is Vi pills of medication a day). The management explained that, if necessary, nurses consult with the responsible registered nurse or the head of health care (both have many years’ experience in the field of psychiatric health care) before starting a therapy. The retirement home has an agreement with the resident psychiatrist that before starting a therapy “as needed” (although it was prescribed in the medical record) the therapy is not administered without prior consultation (by e-mail or phone). The management explained that they were particularly cautious when administering therapy “as needed” and administered it very rarely and according to the aforementioned procedure. The Ministry of Labour, Family, Social Affairs and Equal Opportunities emphasised that special attention would also be paid to the procedure for prescribing medications within the framework of education which it planned to organise regarding the treatment of dementia patients in institutional care of the elderly. The Ministry agreed that the rules on prescribing medications “as needed” would have to be determined in more detail. IMPLEMENTATION OF THE DUTIES AND POWERS OF THE NPM IN 2016 NATIONAL PREVENTIVE MECHANISM UNDER THE OPTIONAL PROTOCOL TO THE UN CONVENTION AGAINST TORTURE AND OTHER CRUEL, INHUMAN OR DEGRADING TREATMENT OR PUNISHMENT 51