Other Auditors XXXXXX hours on site 8 Total hours off site 5 Technical Experts hours on site hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer XXXXXX Hours 2 Sample Totals Total audit hours on site 16 Total audit hours off site 13 audit hours 29 Number of residents interviewed 3 Number of staff interviewed 4 Number of managers interviewed 2 Number of residents’ records reviewed 5 Number of records reviewed 5 Total number of managers (headcount) 2 Number of medication records reviewed 10 Total number of staff (headcount) 9 Number of relatives interviewed 2 Number of residents’ records reviewed using tracer methodology 2 Number of GPs interviewed 1
not have a locked drawer for safe storage of the medications. is completed, (ii) Ensure that residents self-administrating medicines have their medicines stored safely in a locked drawer. HDS(C)S.2008 Standard 1.4.3: Toilet, Shower, And Bathing Facilities Consumers are provided with adequate toilet/shower/bathing facilities. Consumers are assured privacy when attending to personal hygiene requirements or receiving assistance with personal hygiene requirements. PA Low HDS(C)S.2008 Criterion 1.4.3.1 There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use. PA Low One toilet does not have a hand basin. Review the toilet to ensure hand washing facilities are within close proximity. 180 Continuous Improvement (CI) Report Code Name Description Attainment Finding NZS 8134.1:2008: Health and Disability Services (Core) Standards
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 3.4.5 (HDS(IPC)S.2008:3.4.5) Consumer education occurs in a manner that recognises and meets the communication method, style, and preference of the consumer. Where applicable a record of this education should be kept. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 choose 30, for 6 months choose 180, etc.) Standard 3.5: Surveillance (HDS(IPC)S.2008:3.5) Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme. Attainment and Risk: FA Evidence: The surveillance policy describes and outlines the purpose and methodology for the surveillance of infections. The infection control coordinator uses the information obtained through surveillance to plan and determine infection control activities, resources, and education needs within the facility. The staff report a suspected infection to the RN/manager who develops a short term care plan for the management of the suspected infection. There are guidelines for the definition of infections included in surveillance that include urinary tract infection, respiratory tract infection, and skin and wound infections, skin and soft tissue infections (including cellulitis), eye and gastrointestinal infections. All infections are entered onto a monthly infection analysis form. A monthly report is completed by the infection control co-ordinator, which is distributed to relevant meetings. Trends and quality improvements are identified and monitored. Corrective actions are developed when needed and are implemented. Antibiotic use is monitored. Infection rates over the last year have been low. In May 2014 two residents had recurring urinary tract infections (UTI)s’. The RN/manager introduced daily yoghurts for both residents as researched. There has been a positive outcome with no UTIs over the last two months. The surveillance of infection data assists in evaluating compliance with infection prevention and control practices. The surveillance of infection data assists in evaluating compliance with infection prevention and control practices. Internal audits occur including laundry and cleaning, infection control and hand hygiene audits.