1.4 Obiski v domovih za starejše 1.4 Visits to retirement homes Tudi domovi, ki PVU ne izvajajo, imajo sprejete interne pravilnike, ki urejajo izvajanje PVU in pripravljene obrazce za evidentiranje izvajanja, nekateri od njih pa razpolagajo s pasovi za telesno oviranje (pasovi Segufix). Pri nekaterih pravilnikih in obrazcih smo ugotovili določene pomanjkljivosti (vezane npr. na opredelitev PVU, obvezne rubrike obrazca), za katere smo predlagali, da se odpravijo. Uporaba PVU je možen, ne pa tudi obvezen način umirjanja stanovalcev na VO, zato smo mnenja, da bi bilo smiselno, da imajo obrazci za evidentiranje uporabe PVU-rubriko o izvedenih ukrepih pred uvedbo PVU (npr. pogovor, tehnike deeskalacije, dodatna medikamentozna terapija ...). Dom starejših Kranjska Gora nam je v odzivnem poročilu sporočil, da so naš predlog upoštevali in obrazec dopolnili ter ga priložili odgovoru. Podobno so tudi ostali domovi sprejeli naše predloge in ustrezno dopolnili dokumentacijo (obrazce, pravilnike, izjave ipd.). DPM se strinja z izvedenčevim mnenjem, da je uporaba soglasja s PVU nesmiselna, saj je PVU skrajni ukrep in ga ne gre enačiti z drugimi varovalnimi ukrepi, pri katerih je podaja soglasja možna. V Domu starejših Idila smo ugotovili, da je bil pri nekaterih pacientih na VO izveden PVU in so ti pacienti podali soglasje za zdravljenje na oddelku pod posebnim nadzorom, vendar pa iz zdravstvene dokumentacije ne izhaja, da bi bil pacient sposoben podati soglasje za bivanje na VO, poleg tega v dokumentaciji ni sklepa sodišča za bivanje osebe na VO. DPM je ocenil, da ni ustrezno, da je pri osebi, ki ni mogla podati soglasja, uveden PVU brez sklepa sodišča o bivanju osebe na VO. Kot smo že navedli, smo Domu starejših Idila predlagali, da sproži postopke pred pristojnim sodiščem, ko oseba ni sposobna podati soglasja za bivanje na VO zaradi psihične motnje. Ugotovili smo namreč, da je bila uporaba PVU neustrezna v primerih, ko je pacient podal soglasje za zdravljenje na oddelku pod posebnim nadzorom, saj bi bilo treba v takih primerih sprožiti ustrezen postopek pred sodiščem. Mogoče je sklepati, da se pacient z omejitvijo gibanja, povezano s PVU, ni mogel vnaprej strinjati, razen ko bi pacient z uvedbo PVU soglašal (treba bi bilo dopolniti obrazec o uvedbi PVU »PVU si stanovalec želi sam« s prostorom za podpis stanovalca ob podaji tovrstnega soglasja). Odzivnega poročila Doma starejših Idila do priprave tega letnega poročila še nismo prejeli, saj je bil obisk opravljen konec leta 2014. Glede na predvidljive situacije je na VO mogoče pričakovati potrebo po PVU, npr. pri pacientih z demenco, ki je napredovala, s hudim upadom spoznavnih sposobnosti, pri tistih, pri katerih se pojavijo težave s požiranjem in je potrebno hranjenje prek nazogastrične sonde ipd. V primeru psihomotornega nemira je mogoče pričakovati, da si bo stanovalec sondo poskušal odstraniti in v takih primerih se lahko pokaže potreba po uporabi PVU. Za uporabo sredstev za oviranje je treba zagotoviti primerno opremo (npr. pasovi Segufix), predvsem pa osebje, ki bo ta PVU predpisalo (zdravnik) in nadzorovalo (zdravstvena nega). Domovi praviloma nimajo stalno dostopnega zdravnika, ki bi uporabo PVU predpisal v skladu z ZDZdr, pa tudi ne osebja, ki bi ukrep lahko nadzorovalo (24 ur oziroma ves čas trajanja izvajanja PVU). DPM ob izvajanju svojih zakonsko določenih nalog v praksi ugotavlja razhajanje med trenutno veljavno zakonodajo, ki ureja PVU, in dejansko prakso. Ena od najpogostejših kritik, ki jo DPM sliši ob obiskih socialnovarstvenih zavodov, je pomanjkanje kadra in finančnih sredstev ob izvajanju PVU. DPM na je podlagi dosedanjih izkušenj in mnenj izvedenca DPM predlagal MDDSZ pripravo strokovnih smernic ob zagotovitvi ustreznih finančnih sredstev za implementacijo takšnih strokovnih smernic z zadostnim številom dodatnega osebja ob izvajanju PVU (zagotavljanje stalnega nadzora ob izvajanju PVU, zlasti v nočnem času). The retirement homes which did not use special protection measures had adopted internal rules regulating the implementation of special protection measures and forms for recording the implementation; some of them have immobilisation belts (Segufix belts). In the rules and forms, we detected certain deficiencies (relating to e.g. definition of special protection measures and mandatory sections in the form), and we requested their elimination. The use of special protection measures is a possible, but not mandatory method of calming residents in secure wards, and we thus believe that it would be suitable that a section on the application of measures implemented before the introduction of special protection measures be included in the forms for recording the use of special protection measures (e.g. discussion, de-escalation techniques, additional medicament therapy etc.). In their response, the retirement home in Kranjska Gora stated that they had considered our proposal and amended the form, which they also attached to their report. The other retirement homes also accepted our proposals and suitably supplemented their documentation (forms, rules, statements and similar). The NPM agreed with the expert’s opinion that the application of consent for special protection measures was not suitable, because a special protection measure is the final resort and should not be equated with other protection measures for which consent is possible. In Retirement Home Idila, it was established that special protection measures were implemented with certain residents in the secure ward and that these patients gave their consent for the treatment under special supervision; however, it was not evident from the medical documentation whether such patients were capable of giving consent for accommodation in the secure ward. Furthermore, the court order on the persons’ accommodation in the secure ward was not included in the documentation. The NPM assessed that it was not suitable for special protection measures to be implemented with a person who is unable to give their consent without a court order on the person’s accommodation in the secure ward. As stated above, we proposed to Retirement Home Idila that they instigate proceedings before the relevant court when a person is not capable of giving their consent to accommodation in a secure ward due to a mental disorder. We established that the application of special protection measures was unsuitable in cases when a patient gave their consent for the treatment under special supervision, because suitable proceedings before the court would have to be instigated in such cases. It is possible to conclude that a patient whose liberty was limited due to special protection measures could not have agreed in advance, unless the patient agreed with the application of special protection measures (the form on the application of special protection measures should be supplemented in the section “the resident requested special protection measures” with a section enabling the signature of the resident giving such consent). At the time of drafting this annual report, we had not received the response report from Retirement Home Idila, because the visit took place at the end of 2014. Regarding unpredictable situations, the need for special protection measures can be expected in secure wards, e.g. for patients with progressive dementia, with severe deterioration of cognitive abilities and with those who experience problems swallowing and have to be fed through a nasogastric tube, and similar. In the case of psychomotor agitation, it is possible that a resident will try to remove the tube and the need for the application of special protection measures arises in such cases. Suitable equipment (e.g. Segufix belts) must be provided for the implementation of restraining measures, and staff who order (physician) and supervise (health care) such special protection measures. As a rule, the retirement homes do not have a permanent access to a physician who could order the application of special protection measures in accordance with the ZDZdr, or staff who could supervise the measure (24 hours or for the entire duration of the implementation of the special protection measure). When implementing its legally determined duties, the NPM determined a discrepancy in practice between the applicable legislation regulating special protection measures and actual practice. One of the most frequent criticisms heard by the NPM during its visits to social care institutions is the lack of staff and financial means for the application of special protection measures. On the basis of current experience and the opinions of its expert, the NPM proposed to the Ministry of Labour, Family, Social Affairs and Equal Opportunities that it prepare expert guidelines and ensure suitable financing for the implementation of such expert guidelines with sufficient additional staff for the application of special protection measures (provision of permanent supervision when implementing special protection measures, particularly at night). 104 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 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 105