interventions are home residents did not have care plan. (ii) Two residents (one hospital, one rest meet all identified consistent with, and interventions documented for all home) with Type 2 diabetes and previous histories of care needs. contribute to, meeting identified care needs. hypoglycaemia had no emergency diabetic 2. Ensure that that the consumers' management interventions documented in their long The RN reviews information gathered all wound care assessed and term care plans (link rest home tracer). (iii) A through the use of monitoring charts to documentation desired outcomes. hospital resident on warfarin identified as a medium ensure interventions are documented in complies with the falls risk had no interventions documented in the the care to reflect current care Cairnfield House LTCP care plan to manage this risk. The needs. Evaluation by an RN of wound care interventions that were documented on the incident information obtained through the use of management form following a fall were not transferred onto the monitoring charts was not evidenced for policy. short term care plan (link hospital tracer). two residents with 24 hour behaviour 3. Ensure that all monitoring charts. 2. Three of four wound care plans (two hospital, one monitoring forms rest home) had no on-going assessments of the Wound assessments, treatment and are completed as wound or evaluations of wound care documented. evaluations were in place for one of directed in the care three current wounds (one lesion, two 3. Two hourly were not being documented for plan. skin tears) and one grade one pressure one hospital resident and one rest home resident. 4. Ensure that an area. Adequate pressure management 4. In two of eight files sampled observations noted RN reviews and equipment and supplies were sighted. on a behaviour monitoring chart were not reviewed evaluates all by an RN for any change in care needs. monitoring charts and if required, updates intervention for any change in care needs. 60 days Criterion 1.3.7.1 PA On admission an activities assessment of eight resident files sampled did not have a All residents have a Low is completed and an activities plan is documented activity plan. documented Activities are planned developed. activities plan. and provided/facilitated to develop and maintain strengths (skills, 90 days resources, and interests) that are
interventions are consistent with, and contribute to, meeting the consumers' assessed and desired outcomes. home residents did not have interventions documented for all identified care needs. The RN reviews information gathered through the use of monitoring charts to ensure interventions are documented in the care to reflect current care needs. Evaluation by an RN of information obtained through the use of monitoring charts was not evidenced for two residents with 24 hour behaviour monitoring charts. Wound assessments, treatment and evaluations were in place for one of three current wounds (one lesion, two skin tears) and one grade one pressure area. Adequate pressure management equipment and supplies were sighted. care plan. (ii) Two residents (one hospital, one rest home) with Type 2 diabetes and previous histories of hypoglycaemia had no emergency diabetic management interventions documented in their long term care plans (link rest home tracer). (iii) A hospital resident on warfarin identified as a medium falls risk had no interventions documented in the LTCP care plan to manage this risk. The interventions that were documented on the incident form following a fall were not transferred onto the short term care plan (link hospital tracer). 2. Three of four wound care plans (two hospital, one rest home) had no on-going assessments of the wound or evaluations of wound care documented. 3. Two hourly were not being documented for one hospital resident and one rest home resident. 4. In two of eight files sampled observations noted on a behaviour monitoring chart were not reviewed by an RN for any change in care needs. meet all identified care needs. 2. Ensure that that all wound care documentation complies with the Cairnfield House wound care management policy. 3. Ensure that all monitoring forms are completed as directed in the care plan. 4. Ensure that an RN reviews and evaluates all monitoring charts and if required, updates intervention for any change in care needs. 60 days Criterion 1.3.7.1 Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are PA Low On admission an activities assessment is completed and an activities plan is developed. of eight resident files sampled did not have a documented activity plan. All residents have a documented activities plan. 90 days
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