the CPR form signed by a relative and four out of four dementia care CPR forms had been signed by a relative. The GP had not stated on the one hospital and four dementia care CPR forms if the resident is competent or not competent. HDS(C)S.2008 Standard 1.2.3: Quality And Risk Management Systems The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. PA Low HDS(C)S.2008 Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low (i) There are only health and safety/quality meeting minutes available for May and June in 2014. (ii) May meeting minutes do not reflect discussion of incidents or infections and June minutes do not reflect discussion around incident trends. (iii) Registered nurse meeting minutes for February, June and September 2014 (all that are available) do not reflect discussion of incident or infection trends; (iiv) Three complaints in 2014 document on the complaint investigation that there is to be discussion at registered staff meetings. Registered nurse meeting minutes do not reflect this occurring and this is an area requiring improvement Ensure that health and safety/quality meetings occur regularly and that quality data trends analysis outcomes are discussed in these and registered nurse meetings. Ensure that complaints investigations required outcomes including discussion in meetings occurs. 90 HDS(C)S.2008 Standard 1.2.4: Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected PA Moderate
falls risk for one dementia care resident has not been updated in the care plan. HDS(C)S.2008 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. PA Moderate HDS(C)S.2008 Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. PA Moderate 1) There is no evidence of medication reconciliation on delivery of medicines into the facility. 2) GP prescribing on 18 of 20 medications charts do not meet the legislative requirements for prescribing medications. Brackets are used with one signature for several medications and dittos are used for dates. 3) There are no indications for use of PRN medication on seven of 20 medications charts (XXXXX, , and XXXXXX). 1) Ensure documented evidence of medication reconciliation. 2) Ensure GP prescribing of medications meet legislative requirements. 3) Ensure all PRN medications have an indication for use prescribed on the medication chart. 30 HDS(C)S.2008 Standard 1.4.7: Essential, Emergency, And Security Systems Consumers receive an appropriate and timely response during emergency and security situations. PA Low HDS(C)S.2008 Criterion 1.4.7.1 Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures. PA Low There is not always a staff member on duty with a first aid certificate. Ensure there is a staff member on duty with a first aid certificate at all times. 90 HDS(RMSP)S.2008 Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. PA Low
held against their will; (f) Maintaining culturally safe practice; (g) Desired outcome and criteria for ending restraint (which should be made explicit and, as much as practicable, made clear to the consumer); (h) Possible alternative intervention/strategies. HDS(RMSP)S.2008 Standard 2.2.3: Safe Restraint Use Services use restraint safely PA Moderate HDS(RMSP)S.2008 Criterion 2.2.3.2 Approved restraint is only applied as a last resort, with the least amount of force, after alternative interventions have been considered or attempted and determined inadequate. The decision to approve restraint for a consumer should be made: (a) Only as a last resort to maintain the safety of consumers, service providers or others; (b) Following appropriate planning and preparation; (c) By the most appropriate health professional; (d) When the environment is appropriate and safe for successful initiation; (e) When adequate resources are assembled to ensure safe initiation. PA Moderate (i) Two of the six restraint files sampled do not have restraint use identified in the care plan. One further file does not have interventions to guide staff in restraint use and managing the risks of restraint. (ii) Four of six restraint files sampled do not document the frequency of monitoring required. (iii) One of six restraint files does not have a record of monitoring for the use of a lap belt. (iv) Four of six restraint monitoring forms sighted have not had monitoring completed two to three hourly, or hourly for one resident with a documented monitoring frequency of hourly. (i) Ensure restraint use and the management of the risks of restraint is documented in the care plan. (ii), (iii) and (iv) Ensure monitoring frequency is documented and that monitoring occurs in the stated timeframes. 90 HDS(RMSP)S.2008 Standard 2.2.4: Evaluation Services evaluate all episodes of restraint. PA Low
Standard 1.3.1: Entry To Services (HDS(C)S.2008:1.3.1) Consumers' entry into services is facilitated in a competent, equitable, timely, and respectful manner, when their need for services has been identified. ARC A13.2d; D11.1; D11.2; D13.3; D13.4; D14.1; D14.2; E3.1; E4.1b ARHSS A13.2d; D11.1; D11.2; D13.3; D13.4; D14.1; D14.2 Attainment and Risk: FA Evidence: E4.1.b is written information on the service philosophy and practices particular to the Unit included in the information pack including (but not limited to): a) the need for a safe environment for self and others; b) how behaviours different from other Residents are managed and c) specifically designed and flexible programmes, with emphasis on: 1. Minimising restraint. 2. Behaviour management. 3. Complaint policy. D13.3 the admission agreement reviewed aligns with a) -k) of the ARC contract. D14.1 Exclusions from the service are included in the admission agreement. D14.2 the information provided at entry includes examples of how services can be accessed that are not included in the agreement. E3.1 Four files reviewed all include a needs assessment as requiring specialist dementia care. Criterion 1.3.1.4 (HDS(C)S.2008:1.3.1.4) criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)