put in place to ensure best practice for safe administration of medication and safe disposal of used needles/syringes is followed. Criterion 1.3.3.3 PA All residents admitted to the facility had written initial Not all residents had Ensure that all Low assessments, short term and long term care plans and an up to date interRAI residents have an Each stage of service provision evaluations provided with required timeframes. It was assessment or GP interRAI (assessment, planning, provision, evident from staff interviewed that they knew the admission. assessment and are evaluation, review, and exit) is residents well. Family/whanau interviewed stated that admitted by a GP to provided within time frames that safely they were happy with the care and communication meet contractual meet the needs of the consumer. provided. However, one resident admitted in January requirements and 2017 via the hospital for respite care has not been time frames. admitted by a GP, all other GP assessments are within required timeframes. 18 of 23 residents did not have an up to date interRAI assessment. Two of 23 interRAI 180 days assessments were last completed in 2015, 11 interRAI assessments were last completed in 2016. The clinical nurse manager stated that interRAI assessments were not up to date due to high staff turn-over. No corrective action plan is in place at time of audit however a registered nurse employed recently at the facility is interRAI trained and awaiting permission and to have access to the facility database. Criterion 1.3.4.2 PA All residents admitted to the facility had assessment tools Not all residents had Ensure the needs of Low completed. It was evident from staff interviewed that they identified needs all residents are The needs, outcomes, and/or goals of knew the residents well. Family/whanau interviewed documented in the identified in the consumers are identified via the stated that they were happy with the care and support care plan. service delivery assessment process and are communication provided. Two of seven residents’ files planning. documented to serve as the basis for were reviewed, one resident did not have documented in service delivery planning. their short and long term care plans evidence to support the use of a moon boot supporting a fracture. One 180 days resident had evidence to show the need for a restraint, however this was not reflected in the resident’s short or long term care plan.
put in place to ensure best practice for safe administration of medication and safe disposal of used needles/syringes is followed. 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 All residents admitted to the facility had written initial assessments, short term and long term care plans and evaluations provided with required timeframes. It was evident from staff interviewed that they knew the residents well. Family/whanau interviewed stated that they were happy with the care and communication provided. However, one resident admitted in January 2017 via the hospital for respite care has not been admitted by a GP, all other GP assessments are within required timeframes. 18 of 23 residents did not have an up to date interRAI assessment. Two of 23 interRAI assessments were last completed in 2015, 11 interRAI assessments were last completed in 2016. The clinical nurse manager stated that interRAI assessments were not up to date due to high staff turn-over. No corrective action plan is in place at time of audit however a registered nurse employed recently at the facility is interRAI trained and awaiting permission and to have access to the facility database. Not all residents had an up to date interRAI assessment or GP admission. Ensure that all residents have an interRAI assessment and are admitted by a GP to meet contractual requirements and time frames. 180 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 Low All residents admitted to the facility had assessment tools completed. It was evident from staff interviewed that they knew the residents well. Family/whanau interviewed stated that they were happy with the care and communication provided. Two of seven residents’ files were reviewed, one resident did not have documented in their short and long term care plans evidence to support the use of a moon boot supporting a fracture. One resident had evidence to show the need for a restraint, however this was not reflected in the resident’s short or long term care plan. Not all residents had identified needs documented in the support care plan. Ensure the needs of all residents are identified in the service delivery planning. 180 days
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