HDS(C)S.2008 Criterion 1.3.5.2 Service delivery plans describe PA Moderate (i)Six of six resident (i)Ensure there is 90 the required support and/or records reviewed did not documented evidence of intervention to achieve the evidence resident/ resident/family/whanau desired outcomes identified by family/whanau involvement in the care the ongoing assessment involvement in the care planning process. (ii) process. plan process. (ii) of Ensure long term care plans six care plans do not describe the required reflect the current needs support and interventions to of the residents; a) there meet the resident’s needs. are no alternative strategies/activities documented in the care plan for the management of disturbing behaviours for two hospital level residents and one rest home resident. b) There is no diabetic management plan for one rest home resident on insulin and one hospital resident on oral diabetic medication, and c) There is no management plan for one hospital resident with seizures. HDS(C)S.2008 Criterion 1.3.5.3 Service delivery PA Low Activity plans are not Ensure activity are 90 demonstrate service integration. integrated into the integrated into the resident resident files. files. HDS(C)S.2008 Standard 1.3.12: Consumers receive medicines PA Moderate Medicine in a safe and timely manner that Management complies with current legislative requirements and safe practice guidelines. HDS(C)S.2008 Criterion 1.3.12.1 A medicines management PA Moderate Staff have used dittos on Ensure administration 30 system is implemented to five of 12 non-packaged documentation complies with manage the safe and medication signing legislative requirements. appropriate prescribing, sheets. The dose of dispensing, administration, fentanyl patch is not
HDS(C)S.2008 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 Moderate (i)Six of six resident records reviewed did not evidence resident/ family/whanau involvement in the care plan process. (ii) of six care plans do not reflect the current needs of the residents; a) there are no alternative strategies/activities documented in the care plan for the management of disturbing behaviours for two hospital level residents and one rest home resident. b) There is no diabetic management plan for one rest home resident on insulin and one hospital resident on oral diabetic medication, and c) There is no management plan for one hospital resident with seizures. (i)Ensure there is documented evidence of resident/family/whanau involvement in the care planning process. (ii) Ensure long term care plans describe the required support and interventions to meet the resident’s needs. 90 HDS(C)S.2008 Criterion 1.3.5.3 Service delivery demonstrate service integration. PA Low Activity plans are not integrated into the resident files. Ensure activity are integrated into the resident files. 90 HDS(C)S.2008 Standard 1.3.12: Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. PA Moderate HDS(C)S.2008 Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, PA Moderate Staff have used dittos on five of 12 non-packaged medication signing sheets. The dose of fentanyl patch is not Ensure administration documentation complies with legislative requirements. 30
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