Supervision of municipal district nursing services for elderly persons at the municipality of Askim (Askim kommune) 2013

Date:	8/13/2016

The Office of the County Governor of Østfold (Fylkesmannen i Østfold)

Summary

1. Introduction

2. Description of the organisation ̶ special issues

3. Performance of the audit

4. What the supervision covered

5. Findings

6. Assessment of the management system

7. Regulatory requirements

8. Case documents

9. Persons participating in the supervision

Report from the supervision of municipal district nursing services for elderly persons who have been granted an administrative decision for assistance in medication management, and the municipality’s measures to identify assess and follow up elderly persons with dementia living at home, including collaboration with the G.P.s at the municipality of Askim (Askim kommune), Division for Care in the Community and Division for Institutions and Sheltered housing 2013

Summary

From 1 July 2013 to 6 December 2013, the Office of the County Governor of Østfold (Fylkesmannen i Østfold) conducted a supervision of the municipality of Askim’s services for elderly persons living at home. The supervision builds on and is part of a nationwide supervision of services for elderly persons carried out in the period 2009–2013.

During the supervision the Office of the County Governor of Østfold assessed whether the municipality of Askim

ensures that elderly persons living at home and who have been granted an administrative decision for medication management are given the right medicine, administered correctly, at the right time,
ensures that dementia in elderly persons living at home is identified, assessed and followed up,
ensures the necessary collaboration between the municipal health and care services and the G.P.s regarding medication management and looking after elderly persons with dementia living at home.

We uncovered situations constituting the following non-conformities:

The municipality of Askim does not ensure safe medication management for persons living in their own, original homes or in sheltered housing.
The municipality of Askim does not ensure that elderly persons with dementia living at home are followed up so that their basic needs are attended to.

The principal grounds for the non-conformities that were found are as follows:

the management’s lack of oversight over areas in the organisation where there is a risk of failure or of non-compliance with the requirements defined in health and care legislation,
the municipal management’s failure to monitor and control these services.

Siri Bækkevold
Audit leader

Morten Slettmyr
Auditor

1. Introduction

The report has been drawn up following a system audit at the municipality of Askim, Division for Care in the Community and the Division for Institutions and Sheltered Housing, in the period 1 July 2013 – 6 December 2013. The audit forms part of the planned supervisory activities which the Office of the County Governor of Østfold is carrying out this year.

Section 2 of the Act relating to Public Supervision of Health and Care Services gives the Office of the County Governor the authority to supervise the county’s health services.

The objective of the system audit is to assess whether the organisation complies with the various legislative requirements in its internal control activities. The audit comprised assessing:

what measures the organisation has implemented to uncover, correct and prevent any violation of the law in the areas covered by the supervision,
whether the measures are monitored in practice and, where necessary, corrected,
whether the measures are adequate to ensure compliance with the legislation.

A system audit is performed by reviewing documents, carrying out interviews and other forms of investigation.

The report concerns non-conformities that were uncovered during the audit and therefore does not provide a complete appraisal of the status quo as regards the organisation’s work within the areas covered by the supervision.

Non-conformity is the failure to comply with requirements laid down in or in pursuance of laws or regulations.

2. Description of the organisation – special issues

The municipality of Askim’s services to elderly persons living at home are largely provided by the Division Care in the Community and the Division Institutions and Sheltered Housing. In the Division Care in the Community, services are delivered by the District Nursing Service (Wards A and B), the Department for Practical Assistance and the Department for Service Allocation. The sheltered housing units are located at Kirkegata Sheltered Housing (26 flats) and Sommerogata Sheltered Housing (24 flats).

The District Nursing Service provides ordinary medical services carried out by district nurses and practical assistance, including assistance in attending to personal hygiene; dressing and undressing, and with shopping. The Department for Practical Assistance largely offers assistance in the form of cleaning help and laundry.

In the sheltered housing units services such as medical services performed by district nurses and practical assistance are provided by regular staff. This does not apply to the sheltered housing units at Sommerrogata where certain types of practical services are provided by the Department for Practical Assistance.

The divisions’ respective leaders report to the municipal executive, who is on the chief executive’s management team.

In organisational terms the Chief Municipal Medical Officer reports to the Strategy Unit, under the chief executive’s management team.

3. Performance of the audit

The system audit comprised the following activities:

The notification of the audit was sent on 1 July 2013.

A list of the documents the organisation has sent to the auditors in connection with the audit is supplied in the chapter Case documents.

The opening meeting was held on 29 October 2013.

Thirteen people were interviewed.

A list of the documentation that was reviewed during the audit visit is provided in the chapter Case documents.

Inspections were carried out on the premises of the District Nursing Service and in Kirkegata Sheltered Housing.

A closing meeting was held on 30 October 2013.

4. What the supervision covered

The Office of the County Governor of Østfold has considered

whether the municipality of Askim ensures safe medication management, limited to the following issues:
- that the right medication is administered, in the correct dose, to the right service recipient,
- that follow-up of the service recipient is sound,
- that the municipality ensures the necessary collaboration between the District Nursing Service and the G.P.s,
whether the municipality of Askim’s measures to identify, assess and follow up elderly persons with dementia living at home are sound, including:
- that the measures ensure that the service recipients’ basic needs are attended to,
- that the municipality ensures the necessary collaboration between the home care services and the G.P.s.

In this connection we have assessed:

organisation, governance and management,
the distribution of responsibilities, duties and authority,
management of competency and human resources,
measures to facilitate good practice and safeguard against failures,
the management’s monitoring of operations at the municipal home care services, including monitoring:
- whether established routines and procedures are being followed,
- whether established routines and procedures are appropriate and adequate to ensure that medication management and care for elderly persons with dementia living at home are sound,
- whether the municipality implements appropriate corrective measures as required,
- whether the municipality systematically monitors the adequacy of its internal controls with a view to ensuring compliance with the requirements set out in health and care legislation.

5. Findings

Non-conformity 1:

The municipality of Askim does not ensure safe medication management for persons living in their own, original homes or in sheltered housing

Non-conformity from the following regulatory requirements:

Section 3-1, subsection 3, and Sections 4-1, 4-2 and 5-10 of the Health and Care Services Act, Section 4 of the Regulations on Medication Management for Organisations and Health Personnel Providing Healthcare, Sections 5 and 6 of the Regulations on Patient Records, and Section 4 of the Regulations on Internal Control Systems in Social Services and Healthcare.

The non-conformities are based on the following:

There are many and serious errors in the management of medication. The municipality has made efforts to facilitate the uncovering of such errors by establishing a non-conformity reporting system. As a rule the staff use the non-conformity system to report falls, and errors in medication management. However, both employees and leaders lack an understanding of why they are to report such falls, and what the information is used for. The employees are also not clear as to what the reports on medication management non-conformities are used for, beyond the fact that the respective non-conformities are discussed with the employee who has made a mistake.
The municipality has decided that non-conformities shall be closed at the lowest possible level. The municipal management only requests reporting regarding HSE non-conformities. Some non-conformities are discussed by the organisation’s management team, but in practice medication management is handled by the department heads. In addition to discussing the non-conformities with the person who has made the mistake, the department heads use this information when testing out different measures to prevent new errors occurring in the respective departments. The results of such tests and analyses are not shared across departments or divisions with a view to learning, prevention and improvement. Organisation leaders and the municipal management does not monitor whether the measures that are implemented are relevant and adequate, or whether they have the required effect.
Despite the fact that the municipality is aware that there are many errors, some of them serious, in the management of medication, and recently has implemented e-learning measures in order to ensure that all employees have the required relevant capabilities, the municipal management does not follow up this issue especially. For instance, the municipal management has not evaluated whether the upskilling initiatives (or other measures) have had the expected effect (through reviewing non-conformity reports, implementing and monitoring of action plans, analyses, adjusting performance measures, pharmaceutical supervisions or other reviews of the organisations, etc.)
The organisation leaders have no qualifications in the field of medication. Procedure 61357 Responsibility for Medication Management states that the function of providing professional advice is to be carried out by the nursing home consultant (medical practitioner). In practice, this function is not carried out by the nursing home consultant or by anybody else. There is some ambiguity as to what the function entails.
At the Kirkegata Sheltered Housing unit non-prescription as-needed medicine is administered without being prescribed by a doctor. This is done despite the fact that Procedure 61368 states that as-needed medicine shall be prescribed in the same manner as regular medication.
The municipality has procedures stating that patients shall see a doctor when they so require, but no scheme for ensuring a minimum of medical attention by doctors (for instance in order to review the patient's medication needs), is in place.
The municipality’s system for patient medical records is fragmentary. Despite an administrative decision that Gerica is the only system to be used, in fact the system for patient medical records has a number of components: Gerica, a paper-based system of patient records in a separate filing system, as well as a number of folders, books and lists. A lot of the patient information that is relevant and necessary for following up patients is found in folders and books in the nurses’ station and various offices. However, this information is not assembled in a unified fashion in the patients’ medical records. There is no overview or list of where relevant patient information is located.
In the sheltered housing units, the health personnel do not utilise the medical record-keeping system for communication among each other. In the District Nursing Service there is a system in place to facilitate use of the medical record-keeping system for communication. This includes using Gerica to display day-to-day reports on a large screen, and the use of PDAs. The Department for Practical Assistance uses PDAs, but the staff in this department do not communicate with one other or other health personnel (for instance the District Nursing Service) via their PDAs, or directly via the medical record-keeping system.
The management does not monitor whether the practice of medical record-keeping or the medical record system are appropriate or in accordance with legal requirements. Although the municipality has designated certain employees as responsible for the medical records, there is no clarity as to what duties, responsibilities and authority these have.

Non-conformity 2:

The municipality of Askim does not ensure that elderly persons with dementia living at home are followed up so that their basic needs are attended to.

Non-conformity with the following regulatory requirements:

Section 3-1, subsection 3, Sections 4-1, 4-2 and 5-10 of the Health and Care Services Act; Section 3 of the Regulations on Quality in the Health Care Services; Section 3 of the Regulations on Dignified care for the Elderly; Sections 5 and 6 of the Regulations on Patient Records, and Section 4 of the Regulations on Internal Controls in Social Services and Healthcare.

The municipality has not given the staff at the Department for Practical Assistance clear instructions to the effect that they are to observe and report to the organisation any changes in their users, such as signs of beginning dementia. The municipality has recently co-localised the Department for Practical Assistance and the District Nursing Service with a view to exploiting synergies, including making communication between the two departments easier. To date there is no clear understanding of what is to be communicated, or how this is to be done.
The Department for Practical Assistance provides no services on Sundays or public holidays, nor is this compensated through the provision of services on alternative days. No assessment is carried out as to whether it is sound to put off these services.
It is not clear what the municipality’s practice with regard to allocating practical assistance is. The municipality’s information leaflet on practical assistance and sheltered housing lists a number of types of practical assistance that are not provided by the municipality, despite the fact that such assistance is a regulatory requirement. The District Nursing Service procedure (61324) contains examples of practical assistance that are only provided after all other avenues have been explored. This means for instance if close relations are unable to provide such services. However, there are action plans showing that the District Nursing Service provides a variety of types of practical assistance to persons in receipt of district nursing services. This includes types of practical assistance which the municipality states that it does not provide. Administrative decisions that have been issued show that practical assistance involving showering, shaving, food delivery, help with dressing and undressing and shopping help is offered as part of the district nursing service, not as practical assistance.
Despite the fact that the municipality has a procedure stating that the patient's relations have an important role and shall be contacted, the municipality has not clarified when and in which manner the patient's relations shall be involved when signs of beginning dementia are identified. Relations and the G.P. are frequently contacted directly, without any clarification regarding questions of consent and confidentiality.
The municipality has a community dementia team that assesses and evaluates patients. The outcome of the assessments is not followed up by any adjustments in services, action plans or administrative decisions.
Employees’ non-conformity reports are followed up by the department management. The department leaders ensure that specific events are followed up vis-a-vis employees and the patient/user in question. In addition, improvement and preventive measures are put in place in the department. There is a failure to analyse or evaluate information and lessons learned from the events and measures put in place with a view to learning, improvement and prevention across departments and organisations. The municipal management does not monitor whether the measures that have been put in place are relevant and adequate, or whether they have the required effect. Nobody monitors whether the non-conformity system works as intended.
The municipality has procedures stating that patients shall see a doctor as required, but there is no scheme to ensure that they receive a minimum of medical attention from doctors, e.g. for patients who are unable themselves to notify the staff of their needs.
The municipality’s system for patient medical records is fragmentary. Despite an administrative decision that Gerica is the only system to be used, the municipality’s system for patient records consists of Gerica, paper-based patient records in a separate filing system, as well as a number of folders, books and lists. A lot of patient information is to be found in folders and books located in a variety of offices. However, this information is not assembled in a unified fashion in the patients’ medical records.
The community dementia team's assessments are stored in a folder in a separate office, and there is no copy of these assessments in the respective patient records.

6. Assessment of the management system

In medication management there is a risk of small inaccuracies resulting in major consequences, especially for elderly patients. Well-structured practice is therefore essential to ensure satisfactory and correct medication processing, and in order to avoid any adverse medical consequences. One aspect of structured practice is learning from the errors that do occur. Errors often indicate that there are aspects to a system with room for improvement. Do the staff have the relevant capabilities, and are these employed correctly? Is capacity adequate, or does the work load on the individual employee result in a greater likelihood of errors? Does the medical record-keeping system work adequately? Are the procedures updated and to their purpose? It is all a question of facilitating good practice.

Dementia patients are an especially vulnerable group. In order to attend to their basic needs, it is important to identify dementia early on. This requires that the staff have sufficient knowledge of dementia. They need to know what to look out for, and to whom to report their observations. It is the staff providing the patients with practical assistance that are usually the first able to spot signs of dementia. Once signs of dementia are identified, the municipality must make sure that competent personnel act on these observations, and that these staff members are in a position to evaluate whether the patient shall be given further assessment, for instance by a doctor or the community dementia team. The result of this assessment must, in turn, result in services being designed and adjusted in a manner that assures the patient’s or user’s basic needs.

The municipality of Askim has a number of systems for creating standardised practices, such as action plans, function descriptions, procedures, documentation systems, non-conformity systems and reporting systems. The municipality stipulates the type of capabilities employees in different functions must have, and provides for top-up training where required, cf. the Action Plan for Competence Enhancement, the ABC for Dementia Care, and a variety of e-learning measures and training schemes in the field of medication management. The management is in charge of directing competence. The management’s objective is to ensure that the employees’ capabilities benefits the patient who requires this specific competence. Examples include organising the employees in the District Nursing Service into specialised groups; using the community dementia team to assess patients that may be suffering from dementia; procedures for using the G.P. for diagnosing patients, and thoughts on future routine medication reviews with the help of the G.P.s.

Despite the fact that medication management in itself poses great inherent risk for patients, and the fact that non-conformity reports indicate that there are many and serious errors in handling medication in the municipality of Askim, the organisation leaders and the municipal management do not monitor whether the measures implemented “at the lowest level” are appropriate and adequate, or whether they have the required effect. Nor are the medical record-keeping system, procedures or other schemes reviewed regularly in order to make sure that everybody knows what their duties are. Regular reviews are also lacking regarding correct use of the systems, or whether they are useful and facilitate good practice, assuring compliance with the requirements in the health and care legislation.

The municipal management reviews HSE non-conformities, but not non-conformities that might shed light on inadequacies in the services. The non-conformities associated with medication management illustrate that many errors are made, including serious errors, and that the same type of errors occur repeatedly. Moreover, the non-conformities occur in all departments. Given that the management does not request reports or other types of information on the non-conformities and how they are processed there is a failure to identify weaknesses. The inability to pinpoint such weaknesses means that they cannot be used as information to promote good management and facilitating good practice or improving existing practice. The municipality’s failure to follow up and review its services and systems to promote good management leaves too much to chance and individual persons. The resulting risk of errors in medication management is unacceptable. The same applies to the risk of elderly persons with early dementia not having their basic needs met.

7. Regulatory requirements

The Act relating to Municipal Health and Care Services etc. (the Health and Care Services Act)

The Act relating to Public Supervision of Health and Care services etc. (the Health Services Supervision Act)

The Act relating to Procedure in cases concerning the Public Administration (Public Administration Act)

The Regulations for Nursing Services Required by Law in the Municipalities’ Health Service

The Regulations on Internal Control Systems in Social Services and Health Care

The Regulations on Quality in the Health Care Services (the Quality Regulations)

The Regulations on Dignified Care for the Elderly (the Dignified Care Guarantee Regulation)

The Regulations on Patient Records

The Regulations on Medication Management for Organisations and Health Personell Providing Healthcare

The Regulations relating to a Regular G.P. Scheme at the Municipal Level

8. Case documents

The organisation’s own documentation related to day-to-day operations and other matters of significance that were sent to the auditors during preparation for the audit:

Organisation chart for the municipality of Askim, Division for Care in the Community, Division for Care in Institutions and Sheltered housing, the House for Family Services in the municipality and the Strategy Unit.
Lists of employees, Division for Care in the Community and Division for Care in Institutions and Sheltered housing
Manual – rules and delegations
Delegation – authority from the chief executive to the division head
Job descriptions for the department head/senior charge nurse, team leader/first nurse, nurse – Løkentunet, nurse – District Nursing Service – auxiliary nurse/care worker – Løkentunet, auxiliary nurse/care worker – home care services, home help.
Procedures for multidose vials
Procedure: Clinical registration of effect and side effects
Procedure: medication – handing out regular medicines
Procedure: medication – handing out as-needed medicines to the patient
Procedure: medication errors in handing out medicines
Procedure: Responsibility for medication management
Procedure: Contact with relations
Procedure: The District Nursing Service’s collaboration with the G.P.s
Procedure: Registration of Controlled Drugs Schedules 3 and 4 in the home care service
Procedure: Irregularities, theft and burglary
Procedure: Medications – ordering medication in the home care service
Procedure: Medication storage and destruction
Procedure: Medication – preparation and check of pill dispenser
Procedure: Medication – new patients in the home care service without multidose vial
Procedure: Medication – prescribing and stopping medication in home-based services
Course certificate for the Askim Medicines Course
Training and authorisation for medication management
Checklist for practical review in medication management
Authorisation medication management
Overview of employees who have passed the medicines exam, Kirkegata and District Nursing Service, 2013
Quality targets PLO
Procedure: Community-based nursing and care (safe case processing)
Procedure: District nursing service
Procedure: Mapping of care service needs
Mapping tool for dementia assessment
The Community Dementia Team’s manual
Referral to the Community Dementia Team
Procedure: Non-conformity
Procedure: Processing of complaints
Procedures for using Gerica
Municipal plan for the area of health and care services and collaboration 2011-2015
Report: Review of the need for necessary assistance and health care in the home, sheltered housing with additional services and future nursing home places.
Action plan for professional development in the field of nursing and care services in Askim – 2013/2014
Target map - Institutions and Sheltered Housing 2013, 2012, 2011
Target map - Care in the Community 2013, 2012, 2011
Meeting schedule
Minutes from the chief executive’s management team 2013
Minutes from the management team and staff meetings
3Q report, April 2013.
Employee survey 2013.
Performance audit report, 2008, Municipal Audit Office for Indre Østfold.
Leaflets for the community dementia team, the district nursing service, Sommerrogata Sheltered Housing, Kirkegata Sheltered Housing, the Home Help Service ̶ Practical Assistance
Minutes from the collaboration meetings with G.P.s and the District Nursing Service, meetings of the medical practitioners’ Collaboration Committee, the Joint G.P.s’ Committee, and the Indre Østfold Medical Forum
Report: The role of the Chief Municipal Medical Officer, 2012
Copy of the report and follow-up from the Directorate of Labour Inspection’s supervision
Other non-conformity reports for the last year

Documentation reviewed during the visit in connection with the audit:

Administrative decisions concerning patients / users in receipt of practical assistance.
Administrative decisions concerning patients that have been allocated district nursing services and who have a diagnosis of dementia.
Patient records at the Division for Care in the Community, Kirkegata Sheltered Housing and Sommerrogata Sheltered housing.
Folder containing authorisations for employees who are to handle medication.
The community dementia team's folder containing assessments and examinations/mapping of patients with dementia or suspected of suffering from dementia.
Message book, Gerica book, Nurse book, Note book at the nurses' station at the District Nursing Service and at Kirkegata Sheltered housing
Minutes from the Quality Committees

Correspondence between the organisation and the Office of the County Governor of Østfold:

Letter of 1 July 2013 to the municipality of Askim notifying it of the impending supervision
E-mail of 11 July 2013 regarding the appointment of a contact person
Letter from the municipality of Askim of 13 September 2013 7 (with enclosed documents)
E-mail of 27 September 2013 to the municipality of Askim with a request regarding further documents
Letter from the municipality of Askim of 4 October 2013 (with further enclosed documents)

9. Persons participating in the supervision

The table below lists the persons attending the opening and closing meetings, and the persons who were interviewed.

PARTICIPANTS
Name	Function / position	The opening meeting	Interview	Closing meeting
Heidi Eek Guttormsen	Division Head, Care in the Community	X	X	X
Reidun Heksem	Division Head, Institutions and Sheltered housing	X	X	X
Toril Tuft	Case Officer, Care in the Community	X		X
Hilde Staum	Department Head, Department for Service Allocation	X		X
Solfrid Mikalsen	First Nurse, Ward B	X	X	X
Anne Marthe Rydningen	Department Head, Ward B	X		X
Lene Merete Teig	Auxiliary nurse, Kirkegata Sheltered housing	X	X	X
Ola Halvorsen	Senior Charge Nurse, Kirkegata Sheltered housing	X	X	X
Veronica Arnesen	Department Head, Ward A	X	X	X
Elisabeth Bakke	Senior Charge Nurse, Sommerrogata Sheltered Housing	X	X
Gro Anne Skjørten	Auxiliary Nurse, Community Dementia Team	X	X	X
Monica Nordmoen	Municipal Executive	X	X	X
Kim Grana	Physiotherapist, Community Dementia Team		X
Grete Karlsen	Department Head, Practical Assistance	X	X
Anne Grete Overskeid	Auxiliary Nurse	X	X
Alf Johnsen	Chief Municipal Medical Officer	X	X	X
Vigdis Brødremoen	Case Officer, Care in the Community	X		X
Synnøve Rambek	Chief Executive	X		X

The following individuals from the Office of the County Governor participated:

Siri Bækkevold, Senior Advisor (Audit Leader)
Morten Slettmyr, Senior Advisor (auditor)
Maren C. Heldahl, Deputy County Medical Officer (auditor)
Camilla Dingstad, Advisor (observer)