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 There are documented policies, procedures and safe practice guides for all aspects of medicine management. The service has a contracted pharmacist that assists with keeping the service informed of any changes in legislation, protocols and best practice guidelines. There are no standing orders used, with all medications individually prescribed for each resident. The service has a stock of impress medication for administration of medications. The medications, including controlled drugs, are securely stored. The controlled drug register recorded daily checks, weekly stock count check and a six monthly quantity stock count. The medication fridge temperatures were recorded at least weekly. It was noted that some medication fridge recording were below the recommended guidelines, though this is not reflective of a systemic issue, with actions implemented to address any temperature records that fell outside the guidelines. The content of the medication charts complied with legislation and best practice guidelines. Medication management is discussed with the resident on admission, when changes occur and prior to discharge. Any changes in medication are communicated to the resident’s GP. When medication errors occur, there are processes for incident reporting and staff evaluations and learning from any errors. All that assist in medicine management are assessed as competent to perform the role, this includes general medication procedures and competency assessments for subcutaneous medications. There are mandatory medication learning modules for the nursing staff. The medication competency assessment and education is conducted at least annually. Self-administration of medicines is not usually undertaken by the residents at hospital level of care. There are processes in place for the prescriber to assess if the resident is competent to self-administer their medications. A locked box is used to store the patents medications securely in their room. A medication was observed in one of the hospital wards and required protocols were maintained. Twelve medicine records were reviewed and prescribing and sign off are meeting the medication guidelines and relevant legislation.
Specific results for criterion where corrective actions are required 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 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 Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.1.2.3 Opportunities are provided for explanations, discussion, and clarification the Code with the consumer, family/whānau of choice where appropriate and/or their legal representative during contact with the service. PA Low During interview, residents were unaware of their rights, and relatives who had accompanied hospital residents during admission could not recall being told about them and were not familiar with them. Staff stated that people are provided with a copy of the brochure to read at their leisure as so much else happens at admission and they are provided with so much information. They also confirmed that updates are not currently being provided for long term residents and/or relatives. Opportunities to explain, discuss and clarify the Health and Disability Commissioners Code of Health and Disability Services Consumers’ Rights (the Code) are not occurring and the residents and family members interviewed were not familiar with them. Residents and family members/whanau are informed the Health and Disability Commissioners Code of Health and Disability Services Consumers’ Rights (the Code). 180 days Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing PA Low Mandatory training requirements are defined for the different roles. Requirements and timeframes have recently been reviewed. All necessary topics are covered. The Clinical Nurse Manager maintains a spreadsheet of training The mechanism for recording of mandatory training requirements does not support a process to Staff complete all required training within the specified timeframes and there is a