Article Four: Case Study - Professional Misconduct and Poor Professional Performance
“Marian” (not her real name) qualified as a general nurse in Ireland. The events outlined below occurred in Nursing Home A. Nursing Home A caters for over 60 people with age-related and/or chronic conditions; it has a specialist dementia care unit and a small number of beds for people with high-dependency needs. HIQA reports published since the events outlined below have generally been positive about the management and organisation of care.
At the time of the events the induction programme for new staff at Nursing Home A covered policies, procedures and assessments in relation to communication, infection control, hygiene, medication management, record-keeping, risk assessment and HR-related matters. Marian completed the induction programme and was also supported to undertake short courses in CPR, elder abuse, wound care, nutrition, and care of people with dementia.
She worked mostly on night duty and was briefed on what she was expected to do at night. This included hourly checks on all residents, changes of bedding as necessary and repositioning of specific vulnerable residents. The concerns outlined below arose one night when Marian had been working in Nursing Home A for about 18 months.
On the night in question Marian was responsible for the care of twenty-two older people with the assistance of a healthcare assistant. Most of the residents were in bed by 11.30pm and did not require much help going to bed. Two residents were particularly vulnerable. One of them (Miss P) had very limited mobility, a supra-pubic catheter in situ and pressure sores. A pressure-relieving mattress was in use and Miss P was supposed to be repositioned at every two hours. The other vulnerable resident (Mr Q) had a progressive neurological condition and received his nutrition via gastrostomy tube.
According to hand-written records that Marian made during the night, she carried out the hourly checks. In relation to Miss P, Marian recorded that she had repositioned her at 21.00, 23.00, 01.00, 03.00 and 05.00. She wrote in the nursing notes: “Care given as per plan. In good form. Catheter in situ; draining well. Repositioned regularly”. This entry was timed as being written at approximately 23.15.
In respect of Mr Q, Marian recorded in his nursing notes that she had given him his prescribed medications via a PEG tube and in the medication administration record that she had administered his night medication.
The concern arose at the morning hand-over to the director of nursing (Ms J). Marian told Ms J that she had forgotten to administer medication to Mr Q at 22.00. Ms J presumed that Marian had recorded the omission in Mr Q’s nursing notes and medication administration record (in accordance with NMBI’s medication management guidance) and that she had completed an incident report. Later that day Ms J discovered that no such note or report had been made.
Ms J checked a sample of Marian’s notes and noticed that most notes for the residents had been made before midnight. She then went on to check the CCTV footage and observed Marian sitting for long periods without checking the residents and not delivering essential and prescribed care. She was also observed to have prepared medication for administration to more than one resident when she should have prepared it for each individual immediately before administration.
When Marian arrived for work that evening, Ms J and the managing director of Nursing Home A asked her to provide a written account of what she had done the previous night, stating times and tasks. They later cross-referenced this account to the CCTV footage. They concluded that Marian could not have been repositioning Miss P at all the times stated in the hand-written notes because the CCTV footage showed Marian sitting in the nurses station at certain times. It also showed that no other staff member entered Miss P’s room between 20.30 and 02.00.
On completion of the investigation and disciplinary processes, Marian’s contract of employment was terminated and Ms J submitted a complaint to NMBI. Marian did not work as a nurse after her contract was terminated.
Findings of the Fitness to Practise Committee
A two-day inquiry was held in public. The Fitness to Practise Committee heard Ms J’s oral evidence and reviewed documentary evidence. They also heard from a nursing expert.
They found that on the night in question Marian:
failed to carry out hourly checks on 20 out of the 22 people for whom she was responsible
- Guilty of professional misconduct and poor professional performance
failed to reposition Miss P at 21.00, and/or 23.00 and/or 01.00 when she knew or ought to have known that this was required
- Guilty of professional misconduct
completed the check lists when she knew she had not completed the checks in a timely manner
- Guilty of professional misconduct and poor professional performance
recorded that care had been provided to Miss P when she knew this was not the case
- Guilty of professional misconduct and poor professional performance
recorded that medications had been administered to Mr Q when she knew this was not the case.
- Guilty of poor professional performance
prepared medication for administration to more than one resident when she knew that she should have prepared medication individually for each resident immediately prior to administration
- Guilty of poor professional performance
The committee recommended that Marian be censured and have conditions attached to her registration.
Sanction
The Board considered the Fitness to Practise Committee’s report and imposed a censure and the following conditions on Marian’s registration:
That prior to your return to practice as a nurse, you successfully complete and provide evidence to the Board of the following courses:
- A Back to Nursing Course approved by NMBI
- A Medication Management Course approved by NMBI
- A Recognising and Responding to Elder Abuse Course approved by NMBI
Marian was responsible for meeting the costs of the conditions set out above
