Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message data to display” instead of a table, then no corrective actions were required as a result of this audit. “no Criterion with desired Attainment Audit Evidence Audit Finding Corrective action outcome Rating required and timeframe for completion (days) Criterion 1.3.5.2 PA Low Two hospital, two rest home 1) Two hospital, one rest home and one 1) Ensure long-term care and two dementia level of care dementia care resident’s long-term care plans did plans reflect the resident Service delivery plans long-term care plans reflected not document supports to meet the current needs clinical risks and current describe the required the outcomes of assessments of the residents as follows; a) two hospital health status. 2) Ensure support and/or and supports required to residents assessed at high risk of pressure injury the risks associated with intervention to achieve achieve the residents desired did not have appropriate pressure injury restraint use are the desired outcomes goals. Two of four hospital preventions documented in the long-term care documented in the identified by the residents with restraint did not plan. The long-term care plan of one of the care plans. ongoing assessment document the risks associated residents assessed at high risk of falls, did not process. with restraint use in the document appropriate falls prevention strategies. care plans. b) The long-term care plan for one rest home 90 days resident did not reflect the outcome of the InterRAI assessment for falls and associated knee pain. c) There were no documented interventions for the monitoring of oedematous legs as per GP medical notes. 2) The long-term care plans of two hospital residents on restraint did not identify the risks associated with restraint use. Interviews with staff and observation of residents identified that
Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (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 Low Two hospital, two rest home and two dementia level of care long-term care plans reflected the outcomes of assessments and supports required to achieve the residents desired goals. Two of four hospital residents with restraint did not document the risks associated with restraint use in the care plans. 1) Two hospital, one rest home and one dementia care resident’s long-term care plans did not document supports to meet the current needs of the residents as follows; a) two hospital residents assessed at high risk of pressure injury did not have appropriate pressure injury preventions documented in the long-term care plan. The long-term care plan of one of the residents assessed at high risk of falls, did not document appropriate falls prevention strategies. b) The long-term care plan for one rest home resident did not reflect the outcome of the InterRAI assessment for falls and associated knee pain. c) There were no documented interventions for the monitoring of oedematous legs as per GP medical notes. 2) The long-term care plans of two hospital residents on restraint did not identify the risks associated with restraint use. Interviews with staff and observation of residents identified that 1) Ensure long-term care plans reflect the resident clinical risks and current health status. 2) Ensure the risks associated with restraint use are documented in the care plans. 90 days