manage the safe and required to be generated at least recorded reason for medications not and corrective actions appropriate prescribing, monthly. Reports viewed for the last administered for eight doses of implemented. dispensing, administration, two months identified no recorded warfarin (two residents) and two review, storage, disposal, reason for missed medications. doses of antibiotics (two residents). and medicine reconciliation The risk is considered low as the 30 days in order to comply with July report did not record any legislation, protocols, and missed medications. A training guidelines. session relating to the identified issue of correctly recording of medications has been completed. Criterion 1.3.3.4 PA Low Progress notes are maintained daily. Progress notes were reviewed for Ensure resident’s falls are The RN writes into the medical four residents who had sustained documented by the RN and The service is coordinated continuation notes. Caregivers write falls in the month of July 2016. The followed through/integrated in a manner that promotes into separate progress notes. There is falls incident for two residents had into the caregiver progress continuity in service evidence of the RN reviewing the not been documented in the RN or notes. delivery and promotes a caregivers progress notes daily caregiver progress notes. The falls team approach where however, the progress notes reviewed incident for two other residents was appropriate. did not link for residents with falls. documented in the RN progress 90 days notes, but not followed through into the caregiver progress notes. Criterion 1.3.6.1 PA Low Monitoring charts include (but not limited 1) One rest home resident in the Ensure documented to) pain monitoring, blood sugar levels, care apartments did not have a interventions for monitoring The provision of services weight monitoring, wound evaluations, hydration in place to monitor of care are implemented and and/or interventions are food and fluid intake, turning charts, fluid restriction required for a recorded. consistent with, and hydration charts and behaviour medical condition, as per the contribute to, meeting the monitoring. Completed charts including care plan. 2) The rest home consumers' assessed RN reviews were sighted. Three of five respite care resident did not have a 90 days needs, and desired resident files reviewed demonstrated weight taken on admission as outcomes. interventions were in place to monitor required on the initial support plan. care.
manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. required to be generated at least monthly. Reports viewed for the last two months identified no recorded reason for missed medications. recorded reason for medications not administered for eight doses of warfarin (two residents) and two doses of antibiotics (two residents). The risk is considered low as the July report did not record any missed medications. A training session relating to the identified issue of correctly recording of medications has been completed. and corrective actions implemented. 30 days Criterion 1.3.3.4 The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate. PA Low Progress notes are maintained daily. The RN writes into the medical continuation notes. Caregivers write into separate progress notes. There is evidence of the RN reviewing the caregivers progress notes daily however, the progress notes reviewed did not link for residents with falls. Progress notes were reviewed for four residents who had sustained falls in the month of July 2016. The falls incident for two residents had not been documented in the RN or caregiver progress notes. The falls incident for two other residents was documented in the RN progress notes, but not followed through into the caregiver progress notes. Ensure resident’s falls are documented by the RN and followed through/integrated into the caregiver progress notes. 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 Monitoring charts include (but not limited to) pain monitoring, blood sugar levels, weight monitoring, wound evaluations, food and fluid intake, turning charts, hydration charts and behaviour monitoring. Completed charts including RN reviews were sighted. Three of five resident files reviewed demonstrated interventions were in place to monitor care. 1) One rest home resident in the care apartments did not have a hydration in place to monitor fluid restriction required for a medical condition, as per the care plan. 2) The rest home respite care resident did not have a weight taken on admission as required on the initial support plan. Ensure documented interventions for monitoring of care are implemented and recorded. 90 days