The aged care regulator has determined that a nursing home at Port Augusta in South Australia's north poses an "immediate and severe risk" to residents.
The Ramsay facility run by Edenfield Family Care was found to be non-compliant with each of the eight industry standards by the Aged Care Quality and Safety Commission after an inspection in November.
The commission found a range of care, governance, staffing and facility problems and that staff were in need of additional training.
Edenfield was ordered to appoint an adviser, provide additional training for staff and banned from receiving federal subsidies for new residents for three months.
Concern about psychoactive medication
One resident who was suffering from an itchy rash was administered psychoactive medication almost a dozen times in 17 days for "agitation and calling out", the report said.
"Progress notes do not show a medicated cream prescribed for the rash was applied prior to administration of additional psychotropic medication."
Another resident was found to have been administered psychoactive medication six times in a fortnight for "wandering behaviours".
In response, the operator said the dangers of chemical restraint had been discussed with the medical officer and that medication for some residents had been stopped.
Residents' rooms locked
The report found staff would lock residents in and out of their rooms to prevent some residents who liked to wander from entering.
On the third day of the inspection, the assessment team found five bedroom doors locked while residents were outside their rooms, and that night four residents locked inside their bedrooms.
The commission concluded residents were not able to move around freely and the practice put "the safety of those [residents] being confined to their rooms at risk".
Edenfield disputed the inspector's assertions about doors being locked and said a staff member who provided information about the practice to the inspector had been misinterpreted.
Unresponsive resident's vitals not recorded
The report also said that a staff member who entered a resident's room in August found the resident unresponsive.
"Progress notes did not include any information describing the time of clinical event ... neurological observations were not recorded and only one set of vital signs were noted," it said.
Two months later, the resident was found unresponsive again.
"There is only one progress note in relation to the event indicating a head-to-toe assessment was undertaken, but the outcome of the assessment is not noted; vital signs and neurological observations were checked but the findings are not noted," the report said.
In response, Edenfield said it would provide training on how to recognise clinical deterioration.
Staff concerns
More than half of the 21 nursing staff told the assessment team that staffing levels were not sufficient to provide an appropriate level of care and services.
Staff members also raised concerns about training.
"Care staff said they have not received formal training regarding early identification of pressure injuries, but would let the clinical staff know if they saw anything different about a consumer's skin condition," the report said.
It noted, however, that "seven clinical and care staff said they do not have sufficient time to attend to [residents'] pressure area care every two hours as directed".
Edenfield Family Care managing director Jesse Selvarajah said the organisation was "both surprised and devastated" by the findings.
"We are working closely with residents, families and staff to rectify any shortcomings that have been identified and to ensure that we continue to deliver the quality care that our residents deserve and expect," Mr Selvarajah said.
"This has included engaging an external advisor to assist in auditing our systems and providing additional professional development to staff."
