disposal comply with current ensure that this legislation, and guidelines. is maintained. 60 days Criterion 1.3.3.1 PA The registered nurses write in separate progress notes to Seven of seven resident Ensure that Moderate the caregivers. Caregiver’s progress notes were brief and files sampled did not interventions, Each stage of service documented every shift. Registered nursing progress notes contain documented assessments provision (assessment, were detailed and described specific interventions or evidence of regular review and reviews by planning, provision, encounters. Registered nurses progress notes contained by registered nurses. registered evaluation, review, and exit) gaps of up to two months where no nursing Progress notes had nurses are is undertaken by suitably interventions/reviews had been documented. periods ranging from one completed and qualified and/or experienced to two months where no documented service providers who are nursing interventions or regularly. competent to perform the assessments were function. documented. 60 days Criterion 1.3.3.3 PA Low Each of the seven files sampled contained an initial (i) Two of the seven Ensure that assessment, an initial care plan, interRAI assessments and resident files sampled had contractual Each stage of service long term care plans. All files contained a current interRAI not had the initial timeframes provision (assessment, assessment where this was required (the younger resident assessment completed around resident planning, provision, did not require an interRAI assessment). Until recently only within 24 hours of assessments evaluation, review, and exit) one of the two registered nurses was trained in interRAI admission (noting that all are met. is provided within time frames assessments, due to difficulty accessing training and were completed within 72 that safely meet the needs of contractual timeframes were not always met. The second hours of admission). the consumer. registered nurse completed interRAI training three months 90 days (ii) Two of seven resident ago and since this time all timeframes have been met and files sampled were not all interRAI assessments have been bought up to date. As reviewed by a GP within the issue has been addressed no finding has been made in two working days of relation to this. However other contractual timeframes were admission where this was not always met. required. All residents who were under the care of the house GP had contractual timeframes in relation to admission assessments met. Faxes sighted provided evidence that the doctors had been notified for residents who had chosen to retain their
disposal comply with current legislation, and guidelines. ensure that this is maintained. 60 days Criterion 1.3.3.1 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function. PA Moderate The registered nurses write in separate progress notes to the caregivers. Caregiver’s progress notes were brief and documented every shift. Registered nursing progress notes were detailed and described specific interventions or encounters. Registered nurses progress notes contained gaps of up to two months where no nursing interventions/reviews had been documented. Seven of seven resident files sampled did not contain documented evidence of regular review by registered nurses. Progress notes had periods ranging from one to two months where no nursing interventions or assessments were documented. Ensure that interventions, assessments and reviews by registered nurses are completed and documented regularly. 60 days Criterion 1.3.3.3 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Low Each of the seven files sampled contained an initial assessment, an initial care plan, interRAI assessments and long term care plans. All files contained a current interRAI assessment where this was required (the younger resident did not require an interRAI assessment). Until recently only one of the two registered nurses was trained in interRAI assessments, due to difficulty accessing training and contractual timeframes were not always met. The second registered nurse completed interRAI training three months ago and since this time all timeframes have been met and all interRAI assessments have been bought up to date. As the issue has been addressed no finding has been made in relation to this. However other contractual timeframes were not always met. All residents who were under the care of the house GP had contractual timeframes in relation to admission assessments met. Faxes sighted provided evidence that the doctors had been notified for residents who had chosen to retain their (i) Two of the seven resident files sampled had not had the initial assessment completed within 24 hours of admission (noting that all were completed within 72 hours of admission). (ii) Two of seven resident files sampled were not reviewed by a GP within two working days of admission where this was required. Ensure that contractual timeframes around resident assessments are met. 90 days
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