administration, review, charts. Improvements are GP since July 2014. (iv) Each medication prescribed on eight requirements and storage, disposal, and required around aspects of of 14 medication charts have not been individually dated. avoid transcribing. medicine reconciliation medication management. in order to comply with legislation, protocols, 30 days and guidelines. Criterion 1.3.5.2 PA The care plan and Care plans did not describe supports required for (i) respite Ensure care plans interventions describe the care resident with an enabler in use. (ii) One hospital resident describe the required Service delivery plans required support to meet the on insulin did not management of supports/interventions describe the required resident needs in one rest hypoglycaemia/hyperglycaemia documented in the care plan, to meet the needs of support and/or home file and two hospital files (iii) one hospital resident recently admitted had no alert in the the residents. intervention to achieve sampled. An improvement in care plan for positive MRSA noted in the discharge summary the desired outcomes care plan documentation is and GP medical notes. A history of falls had not been identified by the required in the respite file and identified on the initial support plan. (iv) challenging behaviours 90 days ongoing assessment three hospital files sampled. identified through assessment and behaviour monitoring for process. one hospital resident has not been documented in the care plan. Criterion 1.3.6.1 PA When a residents condition (i) was no weight recorded on admission for the respite Ensure risk Low changes, the RN initiates a care resident. There was no falls risk assessment completed. assessments are The provision of review and if required a GP or (ii) A weekly weigh has not been commenced as per care plan completed and services and/or nurse specialist consultation. for one hospital resident. interventions are interventions are Relatives interviewed state implemented. consistent with, and their relatives needs are met contribute to, meeting and they are kept informed of the consumers' any health changes. 90 days assessed needs, and Interventions identified for the desired outcomes. rest home respite resident and one hospital resident have not been implemented.
administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. charts. Improvements are required around aspects of medication management. GP since July 2014. (iv) Each medication prescribed on eight of 14 medication charts have not been individually dated. requirements and avoid transcribing. 30 days Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. PA The care plan and interventions describe the required support to meet the resident needs in one rest home file and two hospital files sampled. An improvement in care plan documentation is required in the respite file and three hospital files sampled. Care plans did not describe supports required for (i) respite care resident with an enabler in use. (ii) One hospital resident on insulin did not management of hypoglycaemia/hyperglycaemia documented in the care plan, (iii) one hospital resident recently admitted had no alert in the care plan for positive MRSA noted in the discharge summary and GP medical notes. A history of falls had not been identified on the initial support plan. (iv) challenging behaviours identified through assessment and behaviour monitoring for one hospital resident has not been documented in the care plan. Ensure care plans describe the required supports/interventions to meet the needs of the residents. 90 days Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Low When a residents condition changes, the RN initiates a review and if required a GP or nurse specialist consultation. Relatives interviewed state their relatives needs are met and they are kept informed of any health changes. Interventions identified for the rest home respite resident and one hospital resident have not been implemented. (i) was no weight recorded on admission for the respite care resident. There was no falls risk assessment completed. (ii) A weekly weigh has not been commenced as per care plan for one hospital resident. Ensure risk assessments are completed and interventions are implemented. 90 days