documented to serve as the basis for change in health condition. Not all ii) One hospital resident had not had their all contractual service delivery planning. resident files sampled had evidence InterRAI assessment reviewed with a requirements. that the required assessments had change in health condition. iii) Ensure that been completed. iii) Two rest home and one hospital pain assessments residents with pain (as noted in the are completed for progress notes and medical notes) did not all residents have pain assessments completed. reporting pain. iv) One hospital resident did not have any iv) Ensure that all risk assessments completed on required risk admission. assessments are completed on v) Three residents (two hospital - admission. including the hospital tracer, and one rest home) did not have the medical admission v) Ensure that the assessment fully documented. medical admission assessments are vi) Four resident files sampled (two rest fully documented. home and two hospital) had incomplete continence assessment forms. vi) Ensure that all sections of vii) One rest home resident did not have additional risk the pressure injury assessment forms risk reassessed following the development are completed. of a stage 2 pressure injury. vii) Ensure that residents are reassessed with a change in heath condition. 60 days Criterion 1.3.5.2 PA The registered nurse is responsible for i) One hospital resident had their care i) Ensure that the completing all necessary assessments plan completed before all the risk assessment Service delivery describe the and then using this information to assessments had been completed. process is used to required support and/or intervention to document the care plan. In the files provide information achieve the desired outcomes reviewed one resident had the care plan documented before the
documented to serve as the basis for service delivery planning. change in health condition. Not all resident files sampled had evidence that the required assessments had been completed. ii) One hospital resident had not had their InterRAI assessment reviewed with a change in health condition. iii) Two rest home and one hospital residents with pain (as noted in the progress notes and medical notes) did not have pain assessments completed. iv) One hospital resident did not have any risk assessments completed on admission. v) Three residents (two hospital - including the hospital tracer, and one rest home) did not have the medical admission assessment fully documented. vi) Four resident files sampled (two rest home and two hospital) had incomplete continence assessment forms. vii) One rest home resident did not have the pressure injury risk reassessed following the development of a stage 2 pressure injury. all contractual requirements. iii) Ensure that pain assessments are completed for all residents reporting pain. iv) Ensure that all required risk assessments are completed on admission. v) Ensure that the medical admission assessments are fully documented. vi) Ensure that all sections of additional risk assessment forms are completed. vii) Ensure that residents are reassessed with a change in heath condition. 60 days Criterion 1.3.5.2 Service delivery describe the required support and/or intervention to achieve the desired outcomes PA The registered nurse is responsible for completing all necessary assessments and then using this information to document the care plan. In the files reviewed one resident had the care plan documented before the i) One hospital resident had their care plan completed before all the risk assessments had been completed. i) Ensure that the assessment process is used to provide information
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