disposal, and medicine reconciliation in order to oxygen and suction checks. Not all comply with legislation, protocols, and guidelines. imprest stock medications were within 60 days the expiry date. Criterion 1.3.4.2 PA Relevant risk assessments are Risk assessments had not Ensure applicable Moderate completed on admission in four of the been completed on risk assessments The needs, outcomes, and/or goals of consumers six reviewed. The outcomes of admission for two residents; are completed on are identified via the assessment process and are the risk assessments (including 1) one respite care resident admission. documented to serve as the basis for service interRAI assessments) are reflected with a history of falls did not delivery planning. in the care plans. have a falls risk assessment and there were no falls 60 days prevention strategies documented and 2) there was no pain and pressure injury risk assessment completed for one resident admitted for palliative care. Criterion 1.3.5.2 PA Low Five long-term care and one a) The care plans for two a) Ensure short-term (respite) care plan were long-term residents (one interventions are Service delivery plans describe the required reviewed. One other resident file was ARCC and one ACC documented for support and/or intervention to achieve the desired reviewed for restraint documentation. resident) had not been residents with outcomes identified by the ongoing assessment The care plans for three long-term updated to include weight loss. b) process. residents described the current interventions for weight loss. Ensure the respite supports to meet the resident’s b) The short-term care plan care are needs. for the respite resident had reviewed with each not been updated to include episode of respite falls prevention strategies or care. c) Ensure risks the use and risks of using an are identified and enabler (cot sides). c) One documented for long-term resident with a restraint and enabler restraint did not have the use. associated risks of using a restraint documented in the care plan. 60 days Criterion 2.2.2.1 PA Low In the two sampled discussion The two resident files Ensure with the unit manager (the restraint sampled that use restraint assessments that
disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. oxygen and suction checks. Not all imprest stock medications were within the expiry date. 60 days Criterion 1.3.4.2 The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning. PA Moderate Relevant risk assessments are completed on admission in four of the six reviewed. The outcomes of the risk assessments (including interRAI assessments) are reflected in the care plans. Risk assessments had not been completed on admission for two residents; 1) one respite care resident with a history of falls did not have a falls risk assessment and there were no falls prevention strategies documented and 2) there was no pain and pressure injury risk assessment completed for one resident admitted for palliative care. Ensure applicable risk assessments are completed on admission. 60 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 Five long-term care and one short-term (respite) care plan were reviewed. One other resident file was reviewed for restraint documentation. The care plans for three long-term residents described the current supports to meet the resident’s needs. a) The care plans for two long-term residents (one ARCC and one ACC resident) had not been updated to include interventions for weight loss. b) The short-term care plan for the respite resident had not been updated to include falls prevention strategies or the use and risks of using an enabler (cot sides). c) One long-term resident with a restraint did not have the associated risks of using a restraint documented in the care plan. a) Ensure interventions are documented for residents with weight loss. b) Ensure the respite care are reviewed with each episode of respite care. c) Ensure risks are identified and documented for restraint and enabler use. 60 days Criterion 2.2.2.1 PA Low In the two sampled discussion with the unit manager (the restraint The two resident files sampled that use restraint Ensure assessments that
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