their understanding of restraints and enablers. On the day of audit, the service had four restraints (two bedrails and two lap belts) and no enablers. Infection prevention and control The infection control programme and its content and detail are appropriate for the size, complexity and degree of risk associated with the service. The infection control resource nurse (clinical coordinator) is responsible for coordinating/providing education and training for staff. The infection control manual outlines a comprehensive range of policies, standards and guidelines, training and education of staff and scope of the programme. The infection control resource nurse uses the information obtained through surveillance to determine infection control activities, resources and education needs within the facility. This includes audits of the facility, hand hygiene and surveillance of infection control events and infections. The service engages in benchmarking of infections with an external provider. Staff receive ongoing training in infection control. Summary of attainment The following table summarises the number of standards and criteria audited and the ratings they were awarded. Attainment Rating Continuous Improvement (CI) Fully Attained (FA) Partially Attained Negligible Risk (PA Negligible) Partially Attained Low Risk (PA Low) Partially Attained Moderate Risk (PA Moderate) Partially Attained High Risk (PA High) Partially Attained Critical Risk (PA Critical) Standards 1 48 0 1 0 0 0 Criteria 1 99 0 1 0 0 0 Attainment Rating Unattained Negligible Risk (UA Negligible) Unattained Low Risk (UA Low) Unattained Moderate Risk (UA Moderate) Unattained High Risk (UA High) Unattained Critical Risk (UA Critical)
Electronic records are protected from unauthorised access. Hard copy records are held securely. Residents’ files demonstrate service integration. Entries are legible, timed, dated and signed by the relevant caregiver or nurse, including designation. Electronic records clearly identify staff member and time. Standard 1.3.1: Entry To Services Consumers' into services is facilitated in a competent, equitable, timely, and respectful manner, when their need for services has been identified. FA The service has admission policies and processes in place. Residents receive an information pack outlining services able to be provided, the admission process and entry to the service. The service screens all potential residents prior to entry and records all admission enquires. Residents and relatives interviewed confirmed they received information prior to admission and had the opportunity to discuss the admission agreement with the manager. The admission agreement form in use aligns with the requirements of the ARRC contract. Registered nurses assess all residents on entry to service. Initial information gained is paper based and is included in the resident computer based system. RNs interviewed could describe the entry and admission process. The GP is notified of a new admission. Standard 1.3.10: Transition, Exit, Discharge, Or Transfer Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services. FA The service has a policy that describes guidelines for death, discharge, transfer, documentation and follow-up. A record of transfer documentation is kept on the resident’s file. All relevant information is documented and communicated to the receiving health provider or service. The procedures include a transfer/discharge form and ‘the yellow envelope’ is used. The RNs report that they include copies of all the required information in the envelope. Standard 1.3.12: Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. FA are comprehensive policies and procedures in place for all aspects of medication management, including self-administration. The service utilises two-weekly robotic rolls. All medications were securely and appropriately stored. Registered nurses administer medications and had completed annual medication competencies and education. Caregivers who act as second checker had a medication competency. There was one resident on the day of audit. Self-medication competencies for that resident had been completed. There is a signed agreement with the pharmacy. Medications are checked on arrival and any pharmacy errors recorded and fed back to the supplying pharmacy. The medication folders include a list of specimen signatures and competencies.
Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Attainment Rating Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.3.3.3 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Low The registered nurse completes an initial assessment within twenty-four hours of admission and documents the initial care plan. Four of the four ARCC resident files reviewed identified that InterRAI assessments had been completed outside the required timeframes. Delays had been identified by the service prior to audit and a new schedule had been implemented, and evidence of progress made towards addressing the problem. (i) One InterRAI assessment was not completed within twenty-one days of admission. The sample was increased and a further four new admissions in the last 6 months did not have an interRAI completed within 21 days. (ii) Four InterRAI were completed outside the six-monthly timeframe. Ensure that InterRAI assessments are completed within contractual timeframes. 90 days