communicated to documented on the controlled drug register and the accurately on the accurately on the consumers at a frequency balance of the drug was correct when checked. The administration sheet. administration sheet. and detail to comply with sample size was increased to include one other legislation and guidelines. resident file with controlled drugs recorded. On this instance, the administration sheet and controlled drug 30 days register were correctly recorded. Criterion 1.3.3.3 PA Moderate management was documented in a word Not all wounds for one Document document. One resident (tracer 3) had multiple resident had an assessment assessments for all Each stage of service wounds and assessments were complete for some of completed and progress wounds and evidence provision (assessment, the wounds. All had a plan documented and some had were not consistently of progress against planning, provision, progress notes documented. documented for one wound. each wound when a evaluation, review, and Progress notes did not resident has multiple exit) is provided within time always differentiate progress wounds. frames that safely meet against individual wounds. the needs of the consumer. 30 days Criterion 1.3.3.4 PA Low Documentation of assessment, plans and review of The lack of integrated notes Develop a coordinated wound management was completed on a document makes it difficult for staff to approach to service The service is coordinated for each resident in word on the computer. The long read all information around delivery for in a manner that promotes term care plan is expected to refer to each wound. wound management and the management of continuity in service care plans do not reference wounds for each delivery and promotes a strategies for all wounds. resident with multiple team approach where wounds. appropriate. 180 days Criterion 1.3.8.2 PA Moderate Long term care plans are expected to be reviewed Evidence of a full review Review care plans six every six months or earlier as required. Evidence of a documented six monthly is monthly as per policy. Evaluations are full review documented six monthly is sighted in three not sighted in two of the five documented, of the five files reviewed. files reviewed. indicate the 90 days degree of achievement or response to the support and/or intervention, and
communicated to consumers at a frequency and detail to comply with legislation and guidelines. documented on the controlled drug register and the balance of the drug was correct when checked. The sample size was increased to include one other resident file with controlled drugs recorded. On this instance, the administration sheet and controlled drug register were correctly recorded. accurately on the administration sheet. accurately on the administration sheet. 30 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 Moderate management was documented in a word document. One resident (tracer 3) had multiple wounds and assessments were complete for some of the wounds. All had a plan documented and some had progress notes documented. Not all wounds for one resident had an assessment completed and progress were not consistently documented for one wound. Progress notes did not always differentiate progress against individual wounds. Document assessments for all wounds and evidence of progress against each wound when a resident has multiple wounds. 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 Documentation of assessment, plans and review of wound management was completed on a document for each resident in word on the computer. The long term care plan is expected to refer to each wound. The lack of integrated notes makes it difficult for staff to read all information around wound management and the care plans do not reference strategies for all wounds. Develop a coordinated approach to service delivery for management of wounds for each resident with multiple wounds. 180 days Criterion 1.3.8.2 Evaluations are documented, indicate the degree of achievement or response to the support and/or intervention, and PA Moderate Long term care plans are expected to be reviewed every six months or earlier as required. Evidence of a full review documented six monthly is sighted in three of the five files reviewed. Evidence of a full review documented six monthly is not sighted in two of the five files reviewed. Review care plans six monthly as per policy. 90 days