and, where appropriate, consumers. discussions around quality and risk management programme findings. collated is also analysed. (iii) Ensure staff are informed of the findings. 90 days Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Low A corrective action form is completed when opportunities for improvements are identified. Corrective actions were not consistently signed off by management, to evidence implementation. Corrective action forms are completed where opportunities for improvements are identified, but are not consistently signed off when implemented. Ensure there is evidence of corrective actions being implemented. 90 days Criterion 1.2.8.1 There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. PA Low Current staffing levels meet contractual requirements. An RN is scheduled to begin providing an additional 24 hours of cover (three days a week). This addition to staff is based on the current resident mix of 37 rest home level residents and 22 hospital level residents. It is unclear how staffing levels will be adjusted if more hospital level residents are admitted to the service. (The owner was not available during the audit and the facility manager did not have this information). The staffing plan for the reconfiguration of 15 hospital beds does not identify staffing requirements on the number of hospital beds occupied. The service has not determined how many more staff will need to be employed to cover the increase in hospital residents. Ensure a staffing plan is developed to determine the number and skill mix of staff required as the number of hospital level residents increases. Ensure adequate staff are available to manage the increase in hospital residents. Prior to occupancy days
interventions are consistent with, and contribute to, meeting the consumers' assessed and desired outcomes. home residents did not have interventions documented for all identified care needs. The RN reviews information gathered through the use of monitoring charts to ensure interventions are documented in the care to reflect current care needs. Evaluation by an RN of information obtained through the use of monitoring charts was not evidenced for two residents with 24 hour behaviour monitoring charts. Wound assessments, treatment and evaluations were in place for one of three current wounds (one lesion, two skin tears) and one grade one pressure area. Adequate pressure management equipment and supplies were sighted. care plan. (ii) Two residents (one hospital, one rest home) with Type 2 diabetes and previous histories of hypoglycaemia had no emergency diabetic management interventions documented in their long term care plans (link rest home tracer). (iii) A hospital resident on warfarin identified as a medium falls risk had no interventions documented in the LTCP care plan to manage this risk. The interventions that were documented on the incident form following a fall were not transferred onto the short term care plan (link hospital tracer). 2. Three of four wound care plans (two hospital, one rest home) had no on-going assessments of the wound or evaluations of wound care documented. 3. Two hourly were not being documented for one hospital resident and one rest home resident. 4. In two of eight files sampled observations noted on a behaviour monitoring chart were not reviewed by an RN for any change in care needs. meet all identified care needs. 2. Ensure that that all wound care documentation complies with the Cairnfield House wound care management policy. 3. Ensure that all monitoring forms are completed as directed in the care plan. 4. Ensure that an RN reviews and evaluates all monitoring charts and if required, updates intervention for any change in care needs. 60 days Criterion 1.3.7.1 Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are PA Low On admission an activities assessment is completed and an activities plan is developed. of eight resident files sampled did not have a documented activity plan. All residents have a documented activities plan. 90 days