consistent with, and advanced care planning and palliative care plans. She also risk and challenging behaviours; interventions contribute to, meeting the supports the nursing team for any clinical interventions. and one dementia resident with are consumers' assessed pain issues and on regular documented. PSS Peacehaven and Iona also have access to another needs, and desired controlled drug medication. gerontology NP with mental health focus to support the Iona ii) Ensure that outcomes. wing. Physiotherapist input was evidenced in the resident (ii) One resident in the dementia care plan file including for the resident identified as being a high falls unit had been transferred from interventions risk. another PSS facility from rest are reviewed home level care. The care plan after Verbal and written handover occurs between shifts. had not been reviewed or transferring Progress notes consistently provided detail of updated, to reflect the change in residents one observations/interventions. Wound documentation was care requirements. The InterRAI level of care to reviewed for 19 residents with 36 wounds. Wound care assessment had also not been another. documentation including assessment, plans, progress, completed within the required time evaluations and short-term care plans, were completed for iii) Ensure that frames; and 11 wounds. Long- term care plans reviewed for rest home, wound care hospital and psychogeriatric residents were comprehensive iii) assessments were not assessments and included all care requirements in interventions including fully completed for five wounds, and residents with specific medical conditions, weight loss and and wound progress/evaluation evaluations are undernutrition. had not been fully documented for accurate and 24 wounds reviewed. fully completed. 30 days Criterion 1.4.6.2 PA Low Cleaning and laundry audits are scheduled to take The Cleaning audits have not been Ensure that 2016 audit schedule and completed internal audits were completed as per the 2016 cleaning audits The methods, frequency, reviewed. A laundry audit was completed in January 2016. schedule. are completed and materials used for Cleaning audits have not been conducted. as per the cleaning and laundry internal audit processes are monitored programme. for effectiveness. 60 days Criterion 3.1.3 PA Low The infection control programme is part of the overall quality The 2015 infection prevention and Ensure that the and risk management programme. Infection prevention and control programme has not been infection The organisation has a control activities are conducted. The programme was last reviewed. prevention and clearly defined and reviewed in 2015 for the 2014 year. control documented infection
consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. advanced care planning and palliative care plans. She also supports the nursing team for any clinical interventions. PSS Peacehaven and Iona also have access to another gerontology NP with mental health focus to support the Iona wing. Physiotherapist input was evidenced in the resident file including for the resident identified as being a high falls risk. Verbal and written handover occurs between shifts. Progress notes consistently provided detail of observations/interventions. Wound documentation was reviewed for 19 residents with 36 wounds. Wound care documentation including assessment, plans, progress, evaluations and short-term care plans, were completed for 11 wounds. Long- term care plans reviewed for rest home, hospital and psychogeriatric residents were comprehensive and included all care requirements in interventions including residents with specific medical conditions, weight loss and undernutrition. risk and challenging behaviours; and one dementia resident with pain issues and on regular controlled drug medication. (ii) One resident in the dementia unit had been transferred from another PSS facility from rest home level care. The care plan had not been reviewed or updated, to reflect the change in care requirements. The InterRAI assessment had also not been completed within the required time frames; and iii) assessments were not fully completed for five wounds, and wound progress/evaluation had not been fully documented for 24 wounds reviewed. interventions are documented. ii) Ensure that care plan interventions are reviewed after transferring residents one level of care to another. iii) Ensure that wound care assessments and evaluations are accurate and fully completed. 30 days Criterion 1.4.6.2 The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness. PA Low Cleaning and laundry audits are scheduled to take The 2016 audit schedule and completed internal audits were reviewed. A laundry audit was completed in January 2016. Cleaning audits have not been conducted. Cleaning audits have not been completed as per the 2016 schedule. Ensure that cleaning audits are completed as per the internal audit programme. 60 days Criterion 3.1.3 The organisation has a clearly defined and documented infection PA Low The infection control programme is part of the overall quality and risk management programme. Infection prevention and control activities are conducted. The programme was last reviewed in 2015 for the 2014 year. The 2015 infection prevention and control programme has not been reviewed. Ensure that the infection prevention and control
AuditSummary_PRMS_CommunicatePublish_000003324003.docx