Audit Team Lead Auditor XXXXX Hours on site 14 Hours off site 6 Other Auditors XXXXX hours on site 28 hours off site 5 Technical Experts hours on site Total hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer XXXXX Hours 2 Sample Totals Total audit hours on site 42 audit hours off site 13 Total audit hours 55 Number of residents interviewed 4 Number of interviewed 13 Number of managers interviewed 3 Number of residents’ records reviewed 7 Number of records reviewed 10 Total number of managers (headcount) 5 Number of medication records reviewed 14 Total number of staff (headcount) 108 Number of relatives interviewed 5 Number of residents’ records reviewed using tracer methodology 4 Number of GPs interviewed 1
and ii) there is no MRSA alert or infection control management documented in the care plan. HDS(C)S.2008 Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. PA Moderate HDS(C)S.2008 Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Moderate i) There is no pain assessment or the monitoring of pain for one hospital resident with a new episode of pain (as per GP notes). ii) There is no behaviour management plan or behaviour monitoring chart in place for one hospital resident with altered behaviours. iii) One rest home resident seen by the GP for an episode of aggressive behaviour does not have behaviour monitoring in place as requested by the GP (link 1.3.3). iii) One hospital resident known to have recent hypoglycaemic episodes (as per progress notes/medical notes) i) Ensure pain assessments and monitoring is completed for new episodes of pain. ii) Ensure behaviour monitoring and behaviour management plans are in place for residents with altered behaviours. iii) Ensure blood sugar monitoring frequency is carried out as instructed. 60
had not had daily sugar monitoring for seven consecutive days. HDS(RMSP)S.2008 Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. PA Moderate HDS(RMSP)S.2008 Criterion 2.1.1.4 The use of enablers be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety. PA Moderate There is a keypad lock at the front door of the hospital and the code is not in sight. Therefore, residents and visitors cannot independently enter and exit the facility. A secure outdoor area in the hospital wing (second floor) has a keypad lock to exit to the courtyard that also has high fences. There is also a keypad entrance back into the facility from the courtyard. This restricts residents to use the outdoor area freely and potentially can lead a resident trapped in the outdoor area. Advised that all residents, relatives and visitors must ask for codes to exit doors. As the units are secure, it makes it an environmental restraint for all Ensure that restraint minimisation policy around environmental restraint is fully implemented. Review the current environmental restraint. Ensure the two residents impacted by environmental restraint are reassessed 30