home resident. d) Mental health disorder has not been included in the long term care plan as per specialist 90 days letter for one hospital resident. 3) Short term care plans have not been developed for three residents (two rest home and one hospital) with short term needs. Criterion 1.3.6.1 PA When a resident's condition alters, the There is no documented evidence to reflect the Ensure documented and registered nurses initiate a review and resident’s current health status as follows: a) no fluid implemented interventions The provision of if required, GP or nurse specialist balance record to ensure a 2 litre intake as per reflect the resident’s services and/or consultation. specialist letter. b) no pain assessment or current health status. interventions are documentation for resident who identifies pain, c) consistent with, and weekly weigh has not been completed and there are no contribute to, records of 1.5 litre intake as per care plan d) there are 60 days meeting the no documented interventions for resident with altered consumers' behaviours as per progress notes and medical notes. assessed and desired outcomes. Criterion 1.3.7.1 PA Resident social leisure style profiles The resident social leisure profile has not been Ensure resident social Low are available for completed for one rest home resident. There are no leisure style profiles are Activities are resident/family/whanau to complete in specific/individualised activity plans in five of five completed on admission. planned and admission. The resident’s spiritual, resident files reviewed. There is no evidence of six Ensure residents have an provided/facilitated cultural and brief statement on monthly activity reviews at the same time as the care individualised activity plan to develop and activities is included in the new format plan reviews. that is reviewed at the maintain strengths long term care plan. Activity same time as the care (skills, resources, attendance sheets are maintained. plan. and interests) that are meaningful to the consumer. 180 days Criterion 1.3.8.2 PA Short term care plans are utilised for Two short term care plans dated October 2014 and Ensure short term care Low resident short term needs and February 2015 had not been reviewed. plans are reviewed in a Evaluations are evaluated or resolved with ongoing timely manner. documented, problems added to the long term care consumer-focused, pan. indicate the degree 60 days of achievement or response to the support and/or
home resident. d) Mental health disorder has not been included in the long term care plan as per specialist letter for one hospital resident. 3) Short term care plans have not been developed for three residents (two rest home and one hospital) with short term needs. 90 days Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed and desired outcomes. PA When a resident's condition alters, the registered nurses initiate a review and if required, GP or nurse specialist consultation. There is no documented evidence to reflect the resident’s current health status as follows: a) no fluid balance record to ensure a 2 litre intake as per specialist letter. b) no pain assessment or documentation for resident who identifies pain, c) weekly weigh has not been completed and there are no records of 1.5 litre intake as per care plan d) there are no documented interventions for resident with altered behaviours as per progress notes and medical notes. Ensure documented and implemented interventions reflect the resident’s current health status. 60 days Criterion 1.3.7.1 Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer. PA Low Resident social leisure style profiles are available for resident/family/whanau to complete in admission. The resident’s spiritual, cultural and brief statement on activities is included in the new format long term care plan. Activity attendance sheets are maintained. The resident social leisure profile has not been completed for one rest home resident. There are no specific/individualised activity plans in five of five resident files reviewed. There is no evidence of six monthly activity reviews at the same time as the care plan reviews. Ensure resident social leisure style profiles are completed on admission. Ensure residents have an individualised activity plan that is reviewed at the same time as the care plan. 180 days Criterion 1.3.8.2 Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or PA Low Short term care plans are utilised for resident short term needs and evaluated or resolved with ongoing problems added to the long term care pan. Two short term care plans dated October 2014 and February 2015 had not been reviewed. Ensure short term care plans are reviewed in a timely manner. 60 days