choice are provided with the information they need to make informed choices and give informed consent. Criterion 1.1.10.7 Advance directives PA Low all resuscitation’ Provide evidence the 90 HDS(C)S.2008 ‘Not that are made records are recorded GP assesses and available to service and GP sign off is not documents the providers are acted on consistently recorded resident is competent where valid. on the resuscitation to make resuscitation orders. for decisions. ‘Not resuscitation’ orders are not consistently signed by GPs (four of eight files, two rest home and two hospital) and one of eight files (one rest home) evidences the for resuscitation’ ‘not record is not completed. The facility policy states the GP verifies if a resident is competent to make a resuscitation decision. HDS(C)S.2008 Standard 1.2.9: Consumer information PA Low Consumer Information is uniquely identifiable, Management Systems accurately recorded, current, confidential, and accessible when required. HDS(C)S.2008 Criterion 1.2.9.9 All records are legible PA Low In seven of eight files Ensure that all entries 90 and the name and reviewed, there are in progress designation of the inconsistent include the time of service provider is recordings of time of entry and designation identifiable. entry in progress of person making the notes and inconsistent entry. recording of
choice are provided with the information they need to make informed choices and give informed consent. HDS(C)S.2008 Criterion 1.1.10.7 Advance directives that are made available to service providers are acted on where valid. PA Low ‘Not all resuscitation’ records are recorded and GP sign off is not consistently recorded on the resuscitation orders. ‘Not for resuscitation’ orders are not consistently signed by GPs (four of eight files, two rest home and two hospital) and one of eight files (one rest home) evidences the ‘not for resuscitation’ record is not completed. The facility policy states the GP verifies if a resident is competent to make a resuscitation decision. Provide evidence the GP assesses and documents the resident is competent to make resuscitation decisions. 90 HDS(C)S.2008 Standard 1.2.9: Consumer Information Management Systems Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required. PA Low HDS(C)S.2008 Criterion 1.2.9.9 All records are legible and the name and designation of the service provider is identifiable. PA Low In seven of eight files reviewed, there are inconsistent recordings of time of entry in progress notes and inconsistent recording of Ensure that all entries in progress include the time of entry and designation of person making the entry. 90
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