There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.
Policy review dates are ranging from 2010-2012 and there is no process implemented to ensure that policies are regularly reviewed. This remains an improvement required from the certification audit.
Ensure that polices are reviewed and updated at regular intervals.
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.
There is an internal audit schedule for 2014 and internal audits have not been completed at all. A consumer survey was conducted in 2014 and 14 residents were responded. However, a survey evaluation has not been conducted for follow up and identification of corrective actions. This remains a required improvement from the previous auditor. Survey results are also not communicated to the residents or families.
Ensure that the internal audit schedule is implemented, results are evaluated. Survey results are communicated to participants.
Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation.
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.
Five files (one RN and four caregivers) reviewed showed that there is no performance appraisal completed for the RN and two out of four caregivers.
Ensure that the RN and the caregivers have annual performance appraisals.
Standard 1.3.3: Service Provision Requirements
Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals.
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.
Each stage of service provision is undertaken by the RN. Five resident’s files are reviewed and demonstrated the following shortfalls; 1) one resident was admitted XXXXXXXX
2) There is also another resident who is receiving respite care. This resident does not have admission documentation completed on entry to the service including an initial assessment, care plan and consent forms. Medication chart is also not signed by the GP and the medication reconciliation showed a medication error (wrong time of administration of a drug).
Ensure that initial assessment and care planning is completed within 24 hours of admission and ensure that the local NASC team approval is obtained prior entry to the service particularly residents requiring higher level care.
Consumers' service delivery plans are evaluated in a comprehensive and timely manner.
Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.
D16.4a Care plan evaluations are not completed six monthly and this is evidenced in one of the five files reviewed. Two residents were not due for reviewed and two files had completed care plan evaluations.
Ensure that care plan evaluations are completed at least six monthly.
Standard 1.3.12: Medicine Management
Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.
A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.
10 medication charts are reviewed:
a) four out of 10 medication charts reviewed had medication crossed over but not signed by the prescriber.
b) on one chart, an antibiotic was charted three times a day but on two occasions it was given twice a day only.
c) on one chart, one drug dose was changed but the time of administration of the medication was not recorded.
d) One drug was stopped but it was still in the robotic roll and staff continued to administer it.
e) There is a ‘temporary medication change‘ form in which the RN transcribes frequency of PRN medications. Such as, PRN XXXXXX was instructed to be administered twice a day as a regular medication. This happened on two occasions. In another incident, a medication was transcribed to be given every second day.
f) Two signing sheets had signing gaps.
g) On one chart, three monthly medication review was not signed by the GP.
h) On one chart, dose of insulin was changed. The prescriber crossed over the dose and re-wrote the new dose next to it. . Staff continued to administer the new dose at bed time. The RN stated that according to discussions with the GP, this was a reduction of insulin dose however the time of administration of XXXXX did not changed.
i) Four drugs were expired. Two of those expired in 2012. The other two drugs expired in June and January 2014. One drug was currently not in use XXXX but kept in the drug cabinet.
k). On one chart (respite care resident) – a medication was prescribed to be given at nocte but administered at tea time. This was transcribed onto the medication chart which is not signed by the GP. The medication was dispensed on to the robotic rolls as a tea time medication
1) Transcribing should cease immediately. 2) Expired drugs and discontinued drugs should be returned to supplying pharmacy. 3) Medications to be administered as prescribed. 4) Discontinued medications to be signed by the prescriber and change of dose should be re-written. 5) Ensure that medication administration system complies with the medication care guides for residential aged care.
Service providers responsible for medicine management are competent to perform the function for each stage they manage.
Six staff files reviewed showed that one staff member had current medication competency dated January 2014. One staff member had completed the medication competency but it was not dated and four staff had medication competencies completed in 2012. Staff medication administration competencies are not current. Since the draft report, the provider has advised that all staff have now completed their medication competencies, and have commenced an On-line training course facilitated by the RN, with the current topic as medications.
Ensure that staff administer medication have current medication competency.
Standard 1.3.13: Nutrition, Safe Food, And Fluid Management
A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.
Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.
Dietitian input to the menu has not been obtained since 2008.
Ensure that a dietitian input to the menu is obtained.