90 days Criterion 1.2.4.3 PA Low Ten accident and incident reports One rest home resident with a Ensure all were reviewed. Each adverse event pressure injury did not have an pressure injuries The service provider documents was documented in detail, and accident/incident form completed. are documented adverse, unplanned, or untoward included a full investigation by a on an events including service shortfalls in registered nurse and was signed off accident/incident to identify opportunities to improve by the clinical nurse manager and the form. service delivery, and to identify and facility manager. A report form for a manage risk. pressure injury was not completed. 90 days Criterion 1.2.7.5 PA Low An in-service training programme is Staff attendance at eight mandatory Ensure that all staff being implemented for staff and in 2015-2016 was less than 50%. attend mandatory A system to identify, plan, facilitate, attendance records are being The facility manager and clinical nurse in-service training. and record ongoing education for maintained. The frequency of manager are aware of this shortfall and service providers to provide safe and mandatory training is dependent on they are implementing strategies to effective services to consumers. the type of in-service and ranges from address it. 90 days six months, one year, and two-yearly. Compulsory training includes continence management, nutrition/dietary, manual handling, pressure area care, pain management, rights/advocacy, wound management, and hoist training. Criterion 1.2.9.9 PA Low When reviewing seven clinical i) One continence assessment and two Ensure all records, it was noted that one long-term care plans were not signed or residents’ All records are legible and the name continence assessment and two dated. ii) Six of seven wound care plans assessments and designation of the service provider care plans were not signed or had not been signed by the registered wound care plans is identifiable. dated, and not all wound care plans nurse. and long-term care had been signed. All progress notes plans are signed include the date and time of entry, and and dated. the signature and designation of staff. 90 days
90 days Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in to identify opportunities to improve service delivery, and to identify and manage risk. PA Low Ten accident and incident reports were reviewed. Each adverse event was documented in detail, and included a full investigation by a registered nurse and was signed off by the clinical nurse manager and the facility manager. A report form for a pressure injury was not completed. One rest home resident with a pressure injury did not have an accident/incident form completed. Ensure all pressure injuries are documented on an accident/incident form. 90 days Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Low An in-service training programme is being implemented for staff and attendance records are being maintained. The frequency of mandatory training is dependent on the type of in-service and ranges from six months, one year, and two-yearly. Compulsory training includes continence management, nutrition/dietary, manual handling, pressure area care, pain management, rights/advocacy, wound management, and hoist training. Staff attendance at eight mandatory in 2015-2016 was less than 50%. The facility manager and clinical nurse manager are aware of this shortfall and they are implementing strategies to address it. Ensure that all staff attend mandatory in-service training. 90 days Criterion 1.2.9.9 All records are legible and the name and designation of the service provider is identifiable. PA Low When reviewing seven clinical records, it was noted that one continence assessment and two care plans were not signed or dated, and not all wound care plans had been signed. All progress notes include the date and time of entry, and the signature and designation of staff. i) One continence assessment and two long-term care plans were not signed or dated. ii) Six of seven wound care plans had not been signed by the registered nurse. Ensure all residents’ assessments wound care plans and long-term care plans are signed and dated. 90 days
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