Criterion 1.2.4.3 PA Low D19.3b; There is an incident reporting There is no evidence of Ensure policy that includes definitions, and neurological observations for three neurological The service provider documents adverse, outlines responsibilities including hospital residents and one observations are unplanned, or untoward events including immediate action, reporting, monitoring dementia care resident following commenced for service shortfalls in order to identify and corrective action to minimise and falls with head injury. all falls with head opportunities to improve service delivery, debriefing. All resident injury. and to identify and manage risk. accident/incidents are reported on the correct form. There is documentation in the health status summary of all 90 days incidents. Criterion 1.3.12.1 PA Medication charts were reviewed for 18 i) Residents who are assessed as i) ensure correct Moderate residents (six rest home, six hospital and competent to self-medicate (five and safe A medicines management system is six dementia residents). All charts hospital residents) are their procedure is implemented to manage the safe and reviewed identified that the GP or nurse individual medicine doses by the followed when appropriate prescribing, dispensing, practitioner had seen the resident at registered nurse. Residents are left administering administration, review, storage, disposal, least three monthly. All medications with their medications to take at a medications as and medicine reconciliation in to were signed for and charted time convenient to them. The RN per facility policy comply with legislation, protocols, and appropriately including reasons for use then signs that the resident has and medicine guidelines. for PRN medication. Medication charts taken the medications, however, care guidelines are legible, and up to date. Medication the nurse has not witnessed the 2011; ii) charts have photo ID’s and allergies ingestion of the medicines. This document insulin noted. practice does not align with facility doses on policy for administration; ii) separate signing residents with insulin are given the sheets. iii) correct doses at the correct time as ensure per the medication order, however, antipsychotic signing for the insulin is not injections are recorded on a separate signing given as sheet. It is included in the general prescribed. pre-packed medications signing sheet. Specific times and dose are not recorded. Two staff check all 30 days insulin prior to administration. iii) one resident on two weekly antipsychotic injections has missed a dose.
Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. PA Low D19.3b; There is an incident reporting policy that includes definitions, and outlines responsibilities including immediate action, reporting, monitoring and corrective action to minimise and debriefing. All resident accident/incidents are reported on the correct form. There is documentation in the health status summary of all incidents. There is no evidence of neurological observations for three hospital residents and one dementia care resident following falls with head injury. Ensure neurological observations are commenced for all falls with head injury. 90 days Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in to comply with legislation, protocols, and guidelines. PA Moderate Medication charts were reviewed for 18 residents (six rest home, six hospital and six dementia residents). All charts reviewed identified that the GP or nurse practitioner had seen the resident at least three monthly. All medications were signed for and charted appropriately including reasons for use for PRN medication. Medication charts are legible, and up to date. Medication charts have photo ID’s and allergies noted. i) Residents who are assessed as competent to self-medicate (five hospital residents) are their individual medicine doses by the registered nurse. Residents are left with their medications to take at a time convenient to them. The RN then signs that the resident has taken the medications, however, the nurse has not witnessed the ingestion of the medicines. This practice does not align with facility policy for administration; ii) residents with insulin are given the correct doses at the correct time as per the medication order, however, signing for the insulin is not recorded on a separate signing sheet. It is included in the general pre-packed medications signing sheet. Specific times and dose are not recorded. Two staff check all insulin prior to administration. iii) one resident on two weekly antipsychotic injections has missed a dose. i) ensure correct and safe procedure is followed when administering medications as per facility policy and medicine care guidelines 2011; ii) document insulin doses on separate signing sheets. iii) ensure antipsychotic injections are given as prescribed. 30 days
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