Service delivery describe however this is not always consistent. accurately reflect the describe the required the required support and/or Two residents recently admitted (one hospital support the resident support to achieve desired intervention to achieve the and one rest home), had documentation to requires to meet their outcomes. desired outcomes identified by verify their needs in relation to activities of daily needs. the ongoing assessment living, however no management strategies process. were documented to manage skin integrity 90 days needs, cultural needs, or pressure injury risk (refer 1.3.3.3 and tracer 2). A diabetic resident had no plan of care to manage the resident’s diabetic needs; however the kitchen was providing the resident with a diabetic diet and the residents blood sugar levels were being monitored, as per sighted evidence. Three residents who had fallen had an initial assessment and subsequent documentation completed. Incident reports were completed and families were informed of the incident however no management strategies were documented to identify the required monitoring following the fall. No evidence was sighted monitoring occurred. A resident recently re-admitted, following a complex referral for specialist services, had an increased level of needs in relation to some aspects of care required. Not all of these had been updated in the care plan, and interviews with care staff evidenced some staff not being aware of all aspects of the care the resident required. Evidence verified the GP had been informed of any changes, as requested. A resident exhibiting episodes of challenging behaviour had documentation in the progress notes recording the episodes of challenging behaviour, however there was no management plan that captured suggested management strategies to manage the behaviour.
Service delivery describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. however this is not always consistent. Two residents recently admitted (one hospital and one rest home), had documentation to verify their needs in relation to activities of daily living, however no management strategies were documented to manage skin integrity needs, cultural needs, or pressure injury risk (refer 1.3.3.3 and tracer 2). A diabetic resident had no plan of care to manage the resident’s diabetic needs; however the kitchen was providing the resident with a diabetic diet and the residents blood sugar levels were being monitored, as per sighted evidence. Three residents who had fallen had an initial assessment and subsequent documentation completed. Incident reports were completed and families were informed of the incident however no management strategies were documented to identify the required monitoring following the fall. No evidence was sighted monitoring occurred. A resident recently re-admitted, following a complex referral for specialist services, had an increased level of needs in relation to some aspects of care required. Not all of these had been updated in the care plan, and interviews with care staff evidenced some staff not being aware of all aspects of the care the resident required. Evidence verified the GP had been informed of any changes, as requested. A resident exhibiting episodes of challenging behaviour had documentation in the progress notes recording the episodes of challenging behaviour, however there was no management plan that captured suggested management strategies to manage the behaviour. accurately reflect the support the resident requires to meet their needs. describe the required support to achieve desired outcomes. 90 days
AuditSummary_PRMS_CommunicatePublish_000003334002.docx