Criterion 1.2.8.1 PA Low Bupa Te Whanau has a roster (i) The home’ includes Ensure is sufficient ‘rest where all staff are rostered to eight hospital level residents) as staff with a correct skill There is a clearly documented and various shifts and specific evidenced by staff interviews and mix to meet resident’s implemented process which determines area. The roster does not review of the roster does not always needs at all times. service provider levels and skill mixes in provide adequate cover of include sufficient staff to support the order to provide safe service delivery. caregivers in the rest home. needs of residents. (ii) When There are four casual illness or leave create gaps in the 30 days caregivers employed and staff roster, staff are frequently not and management reported replaced. (iii) When acuity that agency staff are not used. increases there is no evidence of Absent staff are frequently not an increase in staffing. This was replaced as sighted on the particularly evident during the roster and confirmed by staff. recent protracted outbreak. (iv) There was no evidence of During the recent outbreak, when staffing being increased when the rest home (which also houses acuity increases. hospital level residents) was fully isolated and locked down there was no registered nurse rostered to cover this isolated area. Criterion 1.3.12.6 PA Low The service uses an Four medication charts and signing Ensure dietary electronic medication sheets reviewed of residents supplements are Medicine management information is management system. Twelve prescribed a dietary supplement, documented as recorded to a level of detail, and of sixteen electronic evidenced gaps in electronic administered as communicated to consumers at a frequency medication signing charts medication signing sheets where prescribed. and detail to comply with legislation and reviewed aligned with the the supplement had not been guidelines. medication chart. administered as prescribed. 30 days Criterion 1.3.5.2 PA Low Four rest home and four Not all care reviewed included Ensure care plans are hospital level care plans were interventions to address all resident updated as resident Service delivery plans describe the required reviewed. All eight care plans needs or had not been updated to need changes. support and/or intervention to achieve the had care plans that included reflect interventions currently being desired outcomes identified by the ongoing most of the assessed needs; implemented. assessment process. however, hospital care plans 60 days (i) One hospital file reviewed did not reviewed had not been document management of constipation, or pain management;
Criterion 1.2.8.1 There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. PA Low Bupa Te Whanau has a roster where all staff are rostered to various shifts and specific area. The roster does not provide adequate cover of caregivers in the rest home. There are four casual caregivers employed and staff and management reported that agency staff are not used. Absent staff are frequently not replaced as sighted on the roster and confirmed by staff. There was no evidence of staffing being increased when acuity increases. (i) The ‘rest home’ includes eight hospital level residents) as evidenced by staff interviews and review of the roster does not always include sufficient staff to support the needs of residents. (ii) When illness or leave create gaps in the roster, staff are frequently not replaced. (iii) When acuity increases there is no evidence of an increase in staffing. This was particularly evident during the recent protracted outbreak. (iv) During the recent outbreak, when the rest home (which also houses hospital level residents) was fully isolated and locked down there was no registered nurse rostered to cover this isolated area. Ensure is sufficient staff with a correct skill mix to meet resident’s needs at all times. 30 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 Low The service uses an electronic medication management system. Twelve of sixteen electronic medication signing charts reviewed aligned with the medication chart. Four medication charts and signing sheets reviewed of residents prescribed a dietary supplement, evidenced gaps in electronic medication signing sheets where the supplement had not been administered as prescribed. Ensure dietary supplements are documented as administered as prescribed. 30 days 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 Low Four rest home and four hospital level care plans were reviewed. All eight care plans had care plans that included most of the assessed needs; however, hospital care plans reviewed had not been Not all care reviewed included interventions to address all resident needs or had not been updated to reflect interventions currently being implemented. (i) One hospital file reviewed did not document management of constipation, or pain management; Ensure care plans are updated as resident need changes. 60 days
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