the basis for service were aware of the individual resident’s triggers or delivery planning. the management of the individual challenging behaviours of residents. All of the six files reviewed of the residents’ with challenging behaviour did not evidence challenging behaviour assessments. In the resident’s file of a resident who was assessed by the GP as requiring PRN pain relief did not evidence the effectiveness of the treatment (the PRN pain medication) on the pain monitoring tool or in the progress notes or reassessment of pain assessment completed medication chart evidenced the PRN pain relief was changed to regular pain relief to manage the pain. Criterion 1.3.5.2 PA Moderate All six reviewed of the residents’ with The long term care plans do Provide evidence the long challenging behaviour did not evidence not consistently describes the term care plans describe Service delivery plans challenging behaviour assessments (criterion required interventions around the required support and describe the required 1.3.4.2). The care plan interventions do not behaviours that challenge. interventions relating to support and/or consistently reflect individualised care behaviours that intervention to achieve requirements relating to behaviours that challenge challenge. the desired outcomes (six of six files). identified by the ongoing assessment process. 60 days Criterion 1.3.8.2 PA Moderate I) Two of eight care plan evaluations did not i) Care plan evaluations are Provide evidence that evaluate all identified patients’ needs; such as not consistently recorded for evaluations are Evaluations are challenging behaviour and medical condition. Two all identified needs and do not documented for all documented, of eight care plan evaluations (different files) did always indicate the degree of resident’s care needs and indicate the not record evidence of the degree of achievement achievement towards meeting record the degree of degree of achievement or towards meeting the residents’ needs. Additional residents’ goals. ii) achievement towards response to the support six hospital files were reviewed in relation to care Evaluations of wounds are not meeting these needs. and/or intervention, and plan evaluation. Two of the six additional hospital always completed according progress towards files did not record the evidence of the degree of to the wound care plan meeting the desired achievement towards meeting the resident’s evaluation timeframes. 60 days outcome. needs.
the basis for service delivery planning. were aware of the individual resident’s triggers or the management of the individual challenging behaviours of residents. All of the six files reviewed of the residents’ with challenging behaviour did not evidence challenging behaviour assessments. In the resident’s file of a resident who was assessed by the GP as requiring PRN pain relief did not evidence the effectiveness of the treatment (the PRN pain medication) on the pain monitoring tool or in the progress notes or reassessment of pain assessment completed medication chart evidenced the PRN pain relief was changed to regular pain relief to manage the pain. 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 Moderate All six reviewed of the residents’ with challenging behaviour did not evidence challenging behaviour assessments (criterion 1.3.4.2). The care plan interventions do not consistently reflect individualised care requirements relating to behaviours that challenge (six of six files). The long term care plans do not consistently describes the required interventions around behaviours that challenge. Provide evidence the long term care plans describe the required support and interventions relating to behaviours that challenge. 60 days Criterion 1.3.8.2 Evaluations are documented, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome. PA Moderate I) Two of eight care plan evaluations did not evaluate all identified patients’ needs; such as challenging behaviour and medical condition. Two of eight care plan evaluations (different files) did not record evidence of the degree of achievement towards meeting the residents’ needs. Additional six hospital files were reviewed in relation to care plan evaluation. Two of the six additional hospital files did not record the evidence of the degree of achievement towards meeting the resident’s needs. i) Care plan evaluations are not consistently recorded for all identified needs and do not always indicate the degree of achievement towards meeting residents’ goals. ii) Evaluations of wounds are not always completed according to the wound care plan evaluation timeframes. Provide evidence that evaluations are documented for all resident’s care needs and record the degree of achievement towards meeting these needs. 60 days
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