Summary of attainment The following table summarises the number of standards and criteria audited and the ratings they were awarded. Attainment Rating Continuous Improvement (CI) Fully Attained (FA) Partially Attained Negligible Risk (PA Negligible) Partially Attained Low Risk (PA Low) Partially Attained Moderate Risk (PA Moderate) Partially Attained High Risk (PA High) Partially Attained Critical Risk (PA Critical) Standards 0 13 0 3 1 0 0 Criteria 0 33 0 3 1 0 0 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
consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. advanced care planning and palliative care plans. She also supports the nursing team for any clinical interventions. PSS Peacehaven and Iona also have access to another gerontology NP with mental health focus to support the Iona wing. Physiotherapist input was evidenced in the resident file including for the resident identified as being a high falls risk. Verbal and written handover occurs between shifts. Progress notes consistently provided detail of observations/interventions. Wound documentation was reviewed for 19 residents with 36 wounds. Wound care documentation including assessment, plans, progress, evaluations and short-term care plans, were completed for 11 wounds. Long- term care plans reviewed for rest home, hospital and psychogeriatric residents were comprehensive and included all care requirements in interventions including residents with specific medical conditions, weight loss and undernutrition. risk and challenging behaviours; and one dementia resident with pain issues and on regular controlled drug medication. (ii) One resident in the dementia unit had been transferred from another PSS facility from rest home level care. The care plan had not been reviewed or updated, to reflect the change in care requirements. The InterRAI assessment had also not been completed within the required time frames; and iii) assessments were not fully completed for five wounds, and wound progress/evaluation had not been fully documented for 24 wounds reviewed. interventions are documented. ii) Ensure that care plan interventions are reviewed after transferring residents one level of care to another. iii) Ensure that wound care assessments and evaluations are accurate and fully completed. 30 days Criterion 1.4.6.2 The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness. PA Low Cleaning and laundry audits are scheduled to take The 2016 audit schedule and completed internal audits were reviewed. A laundry audit was completed in January 2016. Cleaning audits have not been conducted. Cleaning audits have not been completed as per the 2016 schedule. Ensure that cleaning audits are completed as per the internal audit programme. 60 days Criterion 3.1.3 The organisation has a clearly defined and documented infection PA Low The infection control programme is part of the overall quality and risk management programme. Infection prevention and control activities are conducted. The programme was last reviewed in 2015 for the 2014 year. The 2015 infection prevention and control programme has not been reviewed. Ensure that the infection prevention and control