had not completed the required required competencies. competency assessments. 60 days Criterion 1.3.12.6 PA The general practitioner prescribes all i) One of 14 medication charts reviewed i) Ensure that all medication to be administered. Five did not have the route or dose time medication is Medicine management information is of fourteen medications evidenced charted for a controlled drug. This was prescribed recorded to a level of detail, and that indications for use were recorded corrected on the day of audit. according to all communicated to consumers at a for required’ medication. One contractual and ‘as frequency and detail to comply with ii) Nine of fourteen medication charts medication did not have the route or legal requirements. legislation and guidelines. reviewed did not have indications for use dose time charted and this was charted for all required’ medication. ii) Ensure that all ‘as corrected on the day of audit. required’ ‘as medication has indications for use charted. 60 days Criterion 1.3.3.3 PA Low Registered nurse’s complete initial Three residents (one rest home, two Ensure that all assessments and care plans within 24 hospital - including one young person with aspects of Each stage of service provision hours of admission. Long-term care disability) had not had their InterRAI assessments and (assessment, planning, provision, plans were completed within 21 days assessments reviewed six monthly. care plans are evaluation, review, and exit) is of admission. InterRAI assessments completed within provided within time frames that safely have been reviewed six monthly for the required meet the needs of the consumer. two of seven residents. Two residents timeframes. do not require the InterRAI assessment completed. 90 days Criterion 1.3.4.2 PA The registered nurses interviewed i) One rest home resident admitted in i-ii) Ensure that the stated that the registered nurses are August 2015 did not have an InterRAI use of the InterRAI The needs, outcomes, and/or goals of responsible for completing the initial assessment completed. tool complies with consumers are identified via the assessments (including InterRAI) and assessment process and are any other assessments required for a
had not completed the required competencies. required competency assessments. 60 days Criterion 1.3.12.6 Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines. PA The general practitioner prescribes all medication to be administered. Five of fourteen medications evidenced that indications for use were recorded for ‘as required’ medication. One medication did not have the route or dose time charted and this was corrected on the day of audit. i) One of 14 medication charts reviewed did not have the route or dose time charted for a controlled drug. This was corrected on the day of audit. ii) Nine of fourteen medication charts reviewed did not have indications for use charted for all ‘as required’ medication. i) Ensure that all medication is prescribed according to all contractual and legal requirements. ii) Ensure that all ‘as required’ medication has indications for use charted. 60 days Criterion 1.3.3.3 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Low Registered nurse’s complete initial assessments and care plans within 24 hours of admission. Long-term care plans were completed within 21 days of admission. InterRAI assessments have been reviewed six monthly for two of seven residents. Two residents do not require the InterRAI assessment completed. Three residents (one rest home, two hospital - including one young person with disability) had not had their InterRAI assessments reviewed six monthly. Ensure that all aspects of assessments and care plans are completed within the required timeframes. 90 days Criterion 1.3.4.2 The needs, outcomes, and/or goals of consumers are identified via the assessment process and are PA The registered nurses interviewed stated that the registered nurses are responsible for completing the initial assessments (including InterRAI) and any other assessments required for a i) One rest home resident admitted in August 2015 did not have an InterRAI assessment completed. i-ii) Ensure that the use of the InterRAI tool complies with