Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message data to display” instead of a table, then no corrective actions were required as a result of this audit. “no Criterion with desired Attainment Evidence Audit Finding Corrective action required outcome Rating and timeframe for completion (days) Criterion 1.3.6.1 PA Moderate Short-term care plans provide 1) There were no short-term care plans 1) Ensure STCPs (or the interventions and guidance for care staff or interventions in the LTCP for; (i) two LTCP updated) to include The provision of when a resident health status changes. hospital residents with pressure interventions to support services and/or Not all health status changes and injuries, (ii) another hospital resident short-term needs. 2) interventions are interventions had been documented in a with a pressure injury and weight loss, Ensure there is adequate consistent with, and STCP or updated in the LTCP. Not all (iii) one rest home with seizures, and pressure injury equipment contribute to, meeting interventions were implemented to (iv) one rest home resident with available. 3) Ensure the consumers' support the resident’s needs. All falls challenging behaviours as documented neurological observations assessed needs, and were recorded on the accident incident on two accident/incident forms. are completed for desired outcomes. form with evidence of timely RN unwitnessed falls. 2) A faulty air alternating mattress had assessment, however there were no not been replaced or available for a neurological observations post hospital resident with pressure injuries unwitnessed falls. 30 days (link hospital tracer). 3) There were no neurological observations for seven unwitnessed falls for the month of December 2017 (noting there was no evidence that the resident had hit their head).
Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Attainment Rating Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Moderate Short-term care plans provide interventions and guidance for care staff when a resident health status changes. Not all health status changes and interventions had been documented in a STCP or updated in the LTCP. Not all interventions were implemented to support the resident’s needs. All falls were recorded on the accident incident form with evidence of timely RN assessment, however there were no neurological observations post unwitnessed falls. 1) There were no short-term care plans or interventions in the LTCP for; (i) two hospital residents with pressure injuries, (ii) another hospital resident with a pressure injury and weight loss, (iii) one rest home with seizures, and (iv) one rest home resident with challenging behaviours as documented on two accident/incident forms. 2) A faulty air alternating mattress had not been replaced or available for a hospital resident with pressure injuries (link hospital tracer). 3) There were no neurological observations for seven unwitnessed falls for the month of December 2017 (noting there was no evidence that the resident had hit their head). 1) Ensure STCPs (or the LTCP updated) to include interventions to support short-term needs. 2) Ensure there is adequate pressure injury equipment available. 3) Ensure neurological observations are completed for unwitnessed falls. 30 days
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