Hiqa report found West Cork nursing home ‘missed’ infections

A Clonakilty nursing home has reviewed their staff training and admissions paperwork after they “missed” that two residents were colonised with multi-drug resistant organisms, that can be resistant to many antibiotics.

Staff were observed to be kind and residents were very complimentary in their feedback about the centre. 

The centre was marked compliant in 13 areas, substantially compliant in five areas, and not compliant in one.

While the majority of the findings of the Hiqa report into Bushmount Nursing Home were positive, Hiqa reported that there were “insufficient assurance mechanisms in place to ensure compliance with the national standards for infection prevention and control.”

An accurate record of residents with previously identified multi-drug resistant organism colonisation was not maintained in the centre.

A review of acute hospital discharge letters, along with laboratory reports, found that staff had not identified a small number of residents that were colonised with the organisms — including vancomycin-resistant enterococci, bacteria that live in the bowel; and carbapenemase-producing enterobacterales, which live in the gut — when discharged from hospitals.

Protocols

This created a risk, as there were specific protocols to follow, even when the infections were no longer active.

As staff and management were unaware that a small number of residents were colonised with these organisms, antimicrobial stewardship measures were not in place for these residents.

Residents colonised with carbapenemase-producing enterobacterales did not have their own en suite toilet and used a communal shower, increasing the risk of cross transmission.

Staff manually decanted the contents of bedpans into toilets, prior to these being placed in the bedpan washer for decontamination, again increasing the risk of environmental contamination and the spread of organism colonisation.

Additionally, hand hygiene facilities were not in line with best practice, with a limited number of sinks available on the first floor.

The Hiqa report also noted that two housekeeping trolleys were visibly unclean — which compromises effective cleaning — and tubs of 70% alcohol wipes were inappropriately used in some areas for cleaning equipment, though these wipes are only effective when used to disinfect already clean surfaces.

Assured

The provider assured Hiqa: “Our infection prevention control audit will be expanded to include staff knowledge of [multi-drug resistant organisms]. Two residents were identified on the day of inspection as having colonised [these organisms]. These were missed on the residents’ transfer from hospital.

“One resident has been moved to a room with an en suite to allow them to have their own bathroom. The second resident has been risk-assessed and controls are now in place to ensure the safe use of communal bathroom for both him and the other residents.

“To ensure this does not occur again, a new check for [the organisms] has been added to our admission and re-admission paperwork.”

The provider added that changes have been made to their cleaning procedures and a new sink has been ordered to address issues raised by Hiqa.