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) Standards 0 0 0 0 0 Criteria 0 0 0 0 0
90 days Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in to identify opportunities to improve service delivery, and to identify and manage risk. PA Low Ten accident and incident reports were reviewed. Each adverse event was documented in detail, and included a full investigation by a registered nurse and was signed off by the clinical nurse manager and the facility manager. A report form for a pressure injury was not completed. One rest home resident with a pressure injury did not have an accident/incident form completed. Ensure all pressure injuries are documented on an accident/incident form. 90 days Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Low An in-service training programme is being implemented for staff and attendance records are being maintained. The frequency of mandatory training is dependent on the type of in-service and ranges from six months, one year, and two-yearly. Compulsory training includes continence management, nutrition/dietary, manual handling, pressure area care, pain management, rights/advocacy, wound management, and hoist training. Staff attendance at eight mandatory in 2015-2016 was less than 50%. The facility manager and clinical nurse manager are aware of this shortfall and they are implementing strategies to address it. Ensure that all staff attend mandatory in-service training. 90 days Criterion 1.2.9.9 All records are legible and the name and designation of the service provider is identifiable. PA Low When reviewing seven clinical records, it was noted that one continence assessment and two care plans were not signed or dated, and not all wound care plans had been signed. All progress notes include the date and time of entry, and the signature and designation of staff. i) One continence assessment and two long-term care plans were not signed or dated. ii) Six of seven wound care plans had not been signed by the registered nurse. Ensure all residents’ assessments wound care plans and long-term care plans are signed and dated. 90 days
Criterion 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. PA Low Residents and family/whānau confirmed on interview that they had received all relevant information on admission. The information pack contains information on the service, resident’s rights and advocacy brochure. Exclusions from the service are included in the admission agreement. The admission agreement in use does not comply with the requirements of the ARRC. The amendments made in 2015 to clause D13.3 of the ARRC contract, regarding refund timeframes are not included in the admission agreement currently in use by the service. Ensure that the current admission agreement aligns fully to the ARRC contract. 90 days 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 The registered nurses in the hospital and senior healthcare assistants in the rest home are responsible for the safe administration of medication. On the two medication rounds observed in the hospital the registered nurses did not follow the correct medication administration process. Ten of fourteen resident medication records had photo identification. All medication charts reviewed had allergies or nil known allergies documented. i) were observed administering medications without prior reference to the medication chart. ii) Four of 14 medication charts (rest home) did not have photo identification on the medication profile. i) Ensure that all staff who administer medication follow acceptable medication administration practices, guidelines and legislative guidelines. ii) Ensure that all medication charts evidence resident photo identification. 60 days Criterion 1.3.12.5 The facilitation of safe of medicines by consumers where appropriate. PA Low Residents who self-administer medication are required to complete a competency assessment every three months. The two residents Two rest home resident’s inhalers had not had the required competency assessment completed in the past 12 months. Ensure that all residents medication complete the
documented to serve as the basis for service delivery planning. change in health condition. Not all resident files sampled had evidence that the required assessments had been completed. ii) One hospital resident had not had their InterRAI assessment reviewed with a change in health condition. iii) Two rest home and one hospital residents with pain (as noted in the progress notes and medical notes) did not have pain assessments completed. iv) One hospital resident did not have any risk assessments completed on admission. v) Three residents (two hospital - including the hospital tracer, and one rest home) did not have the medical admission assessment fully documented. vi) Four resident files sampled (two rest home and two hospital) had incomplete continence assessment forms. vii) One rest home resident did not have the pressure injury risk reassessed following the development of a stage 2 pressure injury. all contractual requirements. iii) Ensure that pain assessments are completed for all residents reporting pain. iv) Ensure that all required risk assessments are completed on admission. v) Ensure that the medical admission assessments are fully documented. vi) Ensure that all sections of additional risk assessment forms are completed. vii) Ensure that residents are reassessed with a change in heath condition. 60 days Criterion 1.3.5.2 Service delivery describe the required support and/or intervention to achieve the desired outcomes PA The registered nurse is responsible for completing all necessary assessments and then using this information to document the care plan. In the files reviewed one resident had the care plan documented before the i) One hospital resident had their care plan completed before all the risk assessments had been completed. i) Ensure that the assessment process is used to provide information
but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided or facilitated; (d) The outcome of the restraint; (e) Any injury to any person as a result of the use of restraint; (f) Observations and monitoring of the consumer during the restraint; (g) Comments resulting from the evaluation of the restraint. otherwise. Restraint monitoring forms that were being completed for the two residents did not reflect two hourly monitoring. The restraint coordinator reports that monitoring is taking place two-hourly or more frequently, but is not being documented. 90 days