HDS(C)S.2008 Standard 1.2.4: All adverse, unplanned, or PA Low Adverse Event untoward events are Reporting systematically recorded by the service and reported to affected consumers and appropriate their family/whānau of choice in an open manner. HDS(C)S.2008 Criterion 1.2.4.3 The service provider documents PA Moderate While incidents are being Ensure there are clear 90 adverse, unplanned, or reported and corrective linkages between reported untoward events including actions discussed during events and individualised service shortfalls in order to staff meetings and noted residents' evaluations and identify opportunities to improve on the incident analysis care plans. 2) Ensure the service delivery, and to identify summary, there is no filing of completed incident and manage risk. clear linkage of the falls reports complies with the related incident data with organisation’s policies. the resident’s six monthly evaluation of care in three of three files sampled. Of the three files sampled one resident had one fall in the preceding six month period, one resident had four falls in the preceding six month period and one resident had 10 falls in the preceding six month period. 2) Whilst falls prevention strategies are developed and discussed (including at staff meetings) some of the prevention strategies have not been linked to the resident’s individual care plan. 3) Completed and analysed incident reports are not consistently filed in
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 consumers and appropriate their family/whānau of choice in an open manner. PA Low HDS(C)S.2008 Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. PA Moderate While incidents are being reported and corrective actions discussed during staff meetings and noted on the incident analysis summary, there is no clear linkage of the falls related incident data with the resident’s six monthly evaluation of care in three of three files sampled. Of the three files sampled one resident had one fall in the preceding six month period, one resident had four falls in the preceding six month period and one resident had 10 falls in the preceding six month period. 2) Whilst falls prevention strategies are developed and discussed (including at staff meetings) some of the prevention strategies have not been linked to the resident’s individual care plan. 3) Completed and analysed incident reports are not consistently filed in Ensure there are clear linkages between reported events and individualised residents' evaluations and care plans. 2) Ensure the filing of completed incident reports complies with the organisation’s policies. 90