1.4 Obiski v domovih za starejše 1.4 Visits to retirement homes Zdravstvena in druga oskrba Medical and other care Zdravstvena oskrba v obiskanih domovih je dobra, prav tako tudi dostopnost do zdravnika splošne medicine in specialista psihiatra. V večino obiskanih domov prihaja zdravnik splošne medicine vsak delovni dan, psihiater 2- ali 3-krat mesečno, možni so tudi posveti po telefonu. Stanovalci VO so v rednih razdobjih, po potrebi pa tudi pogosteje, pregledani pri psihiatru. Medical care in the visited homes was good, including the availability of a general practitioner and a psychiatrist. General practitioners are present in the majority of retirement homes every working day, and psychiatrists are available 2- to 3-times a month; consultations by phone are also possible. Psychiatrists examine the residents of secure wards at regular intervals and more frequently if necessary. Ugotovili smo, da pri delitvi zdravil obstaja potencialna nevarnost napačnega odmerjanja zdravil. V Centru starejših Pristan in Domu starejših Kranjska Gora smo v poročilih o neželenih dogodkih opazili zabeleženih nekaj zapisov napačne medikamentozne terapije. Osebje, ki terapijo deli, se zmoti in da terapijo, ki je predpisana enemu stanovalcu, pomotoma drugemu stanovalcu, zamenjana je jutranja in večerna terapija ipd. Nevarnost napačnega odmerjanja zdravil je po mnenju DPM mogoče zmanjšati tako, da je vedno ista oseba odgovorna za pripravo dnevnih odmerkov zdravil in da zdravila daje oseba, ki stanovalce pozna, da se po potrebi z vprašanjem preverja identiteta stanovalca pred odmerjanjem zdravila ter da stanovalec zdravilo zaužije ob prisotnosti osebja. Popolnoma ni mogoče preprečiti pomote pri odmerjanju zdravil, je pa pomemben ustrezen postopek, da se tovrsten dogodek zabeleži in vedno obvesti zdravnika, ki po potrebi kontaktira dežurnega toksikologa. We established a potential risk of incorrect dosage during the distribution of medication. In the reports on adverse events at Pristan Retirement Home and the retirement home in Kranjska Gora, we noticed several recordings of incorrect medicament therapy. The staff distributing medications made a mistake and gave medication intended for a certain resident to another resident, morning and evening dosages were mixed up and similar. According to the NPM, the risk of incorrect distribution could be reduced if the same person were always responsible for the preparation of daily dosages and if medications were given by someone who knows the residents and verifies their identity if necessary before the distribution of medication, and if residents took their medication in the presence of staff. Errors in distributing medications cannot be avoided completely, but a suitable procedure is important so that such events are recorded and that the physician is always notified, who then contacts the on-duty toxicologist if necessary. Dom starejših Kranjska Gora je v odzivnem poročilu navedel, da je v izogib napačnemu odmerjanju zdravil uredil poseben prostor, kjer poteka priprava zdravil. Locirana je izven domske ambulante, in sicer z namenom izognitve motečim dejavnikom, kot so telefonski klici, vstopi zaposlenih idr. Prav tako je za odmerjanje zdravil zadolžena vedno ista oseba. Stanovalci imajo zdravila, ki so namenjena umirjanju, predpisana v rednem režimu (torej stalno) ali v režimu občasne uporabe (po potrebi). Glede zdravil, ki so predpisana »po potrebi«, smo predlagali, da se v medicinski dokumentaciji stanovalca navede indikacija, kdaj zdravilo odmeriti po potrebi ter kolikokrat največ lahko oseba prejme zdravilo po potrebi v enem dnevu (preprečevanje previsokega odmerjanja). Menili smo, da bi bilo treba pri predpisovanju psihofarmakoterapije pri stanovalcih, ki ne morejo podati soglasja k zdravljenju na VO oziroma k tovrstni terapiji, v nenujnih primerih pridobiti soglasje svojcev in sprožiti ustrezen postopek. Opozorili smo, da je ob predpisovanju terapije nad maksimalnimi priporočenimi dnevnimi odmerki treba postopati v skladu z ZDZdr oziroma uporabiti nižje odmerke. Med neželenimi dogodki v zdravstveni negi in oskrbi se beležijo tudi padci. V enem od obiskanih domov smo v obdobju enega meseca zasledili relativno visoko število zabeleženih tovrstnih dogodkov. Pričakovanega števila padcev ni mogoče predvideti, je pa bilo mogoče v tem domu iskati vzroke za pogoste opise padcev v vestnem spremljanju in beleženju vseh neželenih dogodkov in opredelitvi padcev tudi pri tistih dogodkih, ko je stanovalec najden na tleh brez poškodb in morebitnega padca ni nihče videl, stanovalec pa se ga ne spominja. Tovrstnih dogodkov ni mogoče enoznačno opredeliti za padce, zato smo predlagali, da se ob vrsti dogodka padec doda tudi zdrs. Smiselno bi bilo ločeno spremljanje tistih incidentov, ki so pomenili večje ogrožanje zdravja stanovalca in je bila potrebna pozornost zdravstvenega osebja z napotitvijo v drugo ustanovo, in ločeno tistih incidentov, ki so povzročili manjše tveganje za stanovalčevo zdravje in napotitev na zdravljenje v drugo ustanovo ni bila potrebna. Naslednji možen vzrok (predvsem padcev z ugotovljeno poškodbo, kjer gre nedvoumno za padec) je mogoče iskati v spodbujanju stanovalcev h gibanju, kar je sicer za kakovost življenja stanovalcev dobro, poveča pa verjetnost padcev. V tem domu na oddelku ne uporabljajo PVU, počivalnikov, s katerih stanovalci samostojno ne bi mogli vstati, ali pasov, s katerimi bi onemogočali vstajanje s počivalnikov. Izvedenec DPM na oddelku ni ugotovil, da bi tehnične pomanjkljivosti povzročale večjo nevarnost padcev. Tudi iz zdravstvene dokumentacije ni bilo mogoče ugotoviti, da bi stanovalci prejemali psihofarmakoterapijo v odmerkih, ki bi povečala verjetnost padcev (višji odmerki zlasti benzodiazepinov), stanovalci so bili ob obisku ustrezno obuti, tehnična oprema oddelka je pohvalna. V enem od domov smo glede na število stanovalcev ugotovili relativno visoko število razjed zaradi pritiska. Vendar pa bi bila za natančnejšo oceno potrebna podrobnejša analiza o številu gibalno oviranih stanovalcev in ne le splošen izračun. Domu smo predlagali, da ugotovi, ali obstajajo dodatne možnosti, da bi se število teh zmanjšalo. 106 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 In its response report, the retirement home in Kranjska Gora stated that a special room was arranged where medications would be prepared for distribution in order to avoid incorrect dosages. The room was not part of the home’s infirmary in order to avoid disturbances such as phone calls, entering of staff etc. Only one person was responsible for the distribution of medication. The residents have medications intended for calming which are part of their regular (permanent) or occasional (when needed) treatment. Regarding medications prescribed “when needed”, we proposed that it be recorded in the medical documentation of a resident when such medications are to be prescribed and how many times the person may take such medications per day (preventing excessive dosage). We believe that when prescribing psychopharmacotherapy for residents who are unable to give their consent to accommodation in secure wards or to such treatment, the consent of relatives should be obtained in non-urgent cases and suitable procedures should be instigated. We pointed out that when prescribing medications with recommended maximum daily doses, the provisions of the ZDZdr must be observed or lower dosages must be used. Adverse events in health care include falls. In one of the visited homes, we noted a relatively high number of falls recorded in a period of one month. The number of falls cannot be predicted; however, it was possible to find reasons for frequent falls in regular monitoring and recording of all adverse events and determining falls also when a resident is found on the floor without injuries, when no one sees the fall and when the resident does not remember it. Such events could not clearly be defined as falls, which is why we suggested that slipping also be added to the falls. It would be sensible to monitor separately those events which posed a greater risk to the resident’s health, and greater attention of the medical staff has to be paid, including a relocation to another institution, and events which posed a lesser risk to the resident’s health and for which treatment in another institution was not necessary. Another possible cause (particularly of falls with established injuries when the fall occurred beyond reasonable doubt) lies in encouraging residents to move, which is good for the quality of life of the residents, but also increases the likelihood of falling. In this retirement home, no special protection measures are used or rest chairs from which the residents would not be able to stand up independently or belts which would prevent them getting up from the rest chairs. The NPM expert did not establish at the unit that technical deficiencies would pose an even greater risk of falling. It was also not possible to determine from the medical documentation that residents received psychopharmacotherapy in doses which would increase the likelihood of falling (higher doses of benzodiazepines in particular). During our visit, the residents were wearing suitable footwear, and the technical equipment of the unit was flawless. A relatively high number of pressure ulcers as per the number of residents were established in one retirement home. A more detailed analysis of the number of movement-impaired residents would have to be implemented for a more detailed assessment, not only a general calculation. We suggested that the retirement home explore the possibilities of reducing this number. 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 107