Gol, kommunevåpen

Alvorlige lovbrudd avdekket i Gol

Tilsyn med Gol kommune avdekket tre alvorlig avvik. Innbyggere med utviklingshemming utsettes for ulovlig bruk av tvang og makt, det er mangelfull medisinsk oppfølging og vedtakene om tjenester er så generelle at de gir liten rettsikkerhet.

Fylkesmannens tilsyn med Gol kommune avdekket:

Avvik 1: Gol kommune oppfyller ikke sine forpliktelser etter reglene i helse- og omsorgstjenesteloven kapittel 9

Avviket bygger på følgende observasjoner:

  • Det gjennomføres tiltak som etter loven er å anse som tvang, uten at det er fattet vedtak etter reglene i helse- og omsorgstjenesteloven kapittel 9
  • Det er beskrevet tiltak som etter sin utforming er å anse som tvang, uten at dette er vurdert opp mot reglene i kapittel 9
  • Kommunen har ikke et system for å vurdere brukeres samtykkekompetanse, heller ikke der hvor det er gjort avtaler med brukere
  • Det er ikke et system for etisk refleksjon rundt ansattes samhandling med brukerne
  • Kommunen sikrer ikke at ansatte har tilstrekkelig kompetanse til å identifisere tiltak som er å anse som tvang
  • Ikke alle ansatte har fått opplæring i kapittel 9 om bruk av tvang og makt overfor mennesker med utviklingshemming
  • Det er ikke rutiner for brukermedvirkning.

 

Avvik 2: Gol kommune har ikke tilstrekkelige systemer for å sikre en forsvarlig helseoppfølging overfor mennesker med utviklingshemming

  • Det er ikke systemer som sikrer at ansatte kartlegger endringer i helsetilstand og funksjonsnivå
  • Det er ikke systemer som sikrer at ansatte har kompetanse til å identifisere eller observere symptomer/helseutfordringer knyttet til eksisterende diagnoser og syndromer, herunder symptomer på demens, epilepsi og utfordringer knyttet til kommunikasjon
  • Det er ikke systemer som sikrer informasjonsflyt til/fra fastlege og/eller spesialisthelsetjeneste
  • Det er ingen samlet oversikt over brukernes diagnoser verken i helsepermene eller i Gerica
  • Det er ingen rutiner for hva ansatte skal gjøre dersom det oppstår en medisinsk akuttsituasjon
  • Det er ikke systemer for å observere og vurdere brukers tilstand i etterkant av legekonsultasjon
  • Ikke alle ansatte har gjennomført kurs i førstehjelp
  • Det gjennomføres ikke alltid dobbeltkontroll ved istandgjøring av dosetter
  • Helseperm inneholder signeringslister for mer enn ett år, uten at det alltid er angitt årstall
  • Det har blitt delt ut medisiner uten at doser er angitt.

 

Avvik 3: Gol kommune har ikke systemer som sikrer forsvarlige omsorgstjenester til mennesker med utviklingshemming

  • Innholdet i tjenesten er ikke konkretisert i vedtakene
  • Vedtakene inneholder mange standardformuleringer, og lite opplysninger om hva kommunen har lagt til grunn for tildeling av tjenestene
  • Vedtakene blir ikke systematisk evaluert i forbindelse med endringer i brukeres funksjonsnivå
  • Det er ikke rutiner for å melde om endringer i behov hos den enkelte bruker
  • Vedtakene i brukerpermene som benyttes til daglig samhandling, er i hovedsak gamle
  • Det er ikke alltid samsvar mellom IPLOS-kartlegging og faktum i saken og de tjenestene som brukere får tildelt
  • Det er ikke rutiner for systematisk brukermedvirkning
  • Ansatte får ikke nødvendig opplæring når det gjelder å jobbe med mennesker med utviklingshemming
  • Det er ikke systemer som sikrer tilrettelagt kommunikasjon med brukere
  • Det er ikke dokumentert at primærkontakter får nødvendig tid til primærkontaktoppgaver
  • Det er få muligheter for faglig diskusjon og veiledning
  • Tiltaksplaner er oppdatert, men d som står i brukerpermene som brukes i daglig samhandling, er gamle
  • Det er ikke laget mål for de tjenestene ansatte skal yte overfor den enkelte bruker. Det er heller ikke noe system for å evaluere mål
  • Ansatte skal kvittere ut på sjekklister. Det er ingen rutine for å følge opp disse listene
  • Tiltaksplanene inneholder lite om hvilke aktiviteter brukere skal ha
  • Dags- og ukeplaner har i liten grad beskrivelse av konkrete aktiviteter
  • Det er ikke gjennomført kartlegginger av brukeres behov for aktiviteter. Fanen aktivitetsbank i brukerpermen har ikke innhold
  • Det er ikke klare ansvarslinjer i tjenesten
  • Personer med utviklingshemming som omfattes av tilsynet, har ikke fått oppnevnt koordinator.
  • Primærkontakter har som sin oppgave å koordinere, men dette er ikke kjent for primærkontaktene og de har heller ikke fått noen opplæring på dette
  • Det er mange som samhandler med enkelte brukere i perioden som er gjennomgått i journal. Det er ikke vurdert om dette er forsvarlig overfor den enkelte bruker
  • Det er ikke systemer som sikrer at ansatte jobber mest mulig likt overfor den enkelte bruker
  • Det gjennomføres ikke risiko- og sårbarhetsanalyser.

 

Les tilsynsrapporten om tjenestene til innbyggere med utviklingshemming i Gol kommune

Jens Petter Gitlesen

11 april 2018

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