Waverley Aged Care Limited Current Status: 29 August 2014


Outcome 1.3: Continuum of Service Delivery



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Outcome 1.3: Continuum of Service Delivery


Consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation.

Standard 1.3.3: Service Provision Requirements (HDS(C)S.2008:1.3.3)


Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals.

ARC D3.1c; D9.1; D9.2; D16.3a; D16.3e; D16.3l; D16.5b; D16.5ci; D16.5c.ii; D16.5e ARHSS D3.1c; D9.1; D9.2; D16.3a; D16.3d; D16.5b; D16.5d; D16.5e; D16.5i



Attainment and Risk: PA High

Evidence:

Each stage of the assessment, planning, and provision of care and review is undertaken by the RN who is competent to perform her duties. Although she does not have a formal peer support or mentoring, she has access to a nurse specialist from the local DHB and the local hospice. The RN and the manager confirmed this on interview. An improvement is required around establishment of formal peer support and mentoring. See CAR. 1.2.7.5.

The RN’s responsibility is to conduct the initial assessment and initial care plan on admission to the service, and to develop the long term care plan within three weeks. Initial assessments and care planning and short term care planning are completed on admission in three out of five files reviewed.

In four out of five files, residents care plans are evaluated and interventions updated six monthly or more frequently as the resident needs changes. Evaluation includes consultation with the resident, caregivers, resident`s family and/or whānau. Progress notes are documented by the caregivers and the RN, and are comprehensive. One file reviewed was overdue for care plan evaluations. See CAR-1.3.8.3.

GP notes reviewed evidenced three monthly reviews by the GP or more often as required. Handovers between shifts occur and it promotes continuity of service. Three caregivers interviewed confirmed that they are encouraged to read the progress notes and care plans of each resident. Family/whānau involvement is maintained and sighted in all five residents' files.
Tracer methodology:

XXXXXX This information has been deleted as it is specific to the health care of a resident.
D16.2, 3, 4: Timeframes of service delivery is not met. See CAR-1.3.3.3.

D16.5e: Five resident files reviewed identified that the GP had seen the resident within two working days. Residents are reviewed by the GP on a monthly basis or when residents are stable assessed and reviewed by the GP three monthly.


Criterion 1.3.3.1 (HDS(C)S.2008:1.3.3.1)

Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function.

Attainment and Risk: FA

Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.3.3 (HDS(C)S.2008:1.3.3.3)

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.

Attainment and Risk: PA High

Evidence:

Required corrective action around re assessment of residents who require secure environment for safety has been addressed. The policy has been reviewed and the consent for the acceptance of a locked facility forms are dated and signed on entry to the facility.



Finding:

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 XXXXX There was no initial assessment or care plan completed on admission and to date. Discussions with the manager and the RN confirmed that NASC assessment is not completed and there is no documentation relating to the resident’s placement in the service. The manager stated they have informed the local NASC team, but there is no documented evidence of this. Beginning of the day, staff are concerned that the resident was in pain and the RN notified the hospice. Later in the day, the resident was noted to be comfortable. The RN stated that the hospice had no vacancy and there is no hospital level care bed available locally.

Staffing level is appropriate for the rest home level care, but there is only one night staff on duty and the RN is on call. Caregiving staff do not administer controlled drugs and not all staff who administer medication had current medication administration competency. Staff ‘s capability to provide pain assessment and timely pain medication is quite limited. There was noted to be one other resident requiring two person assistance and the RN stated that hospital level care assessment was requested for this resident. Documentation is sighted.

2) There is also another resident who is receiving respite care and awaiting a bed in another facility. 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).



Corrective Action:

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.



Timeframe (days): 7 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.3.4 (HDS(C)S.2008:1.3.3.4)

The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.

Attainment and Risk: FA

Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Standard 1.3.6: Service Delivery/Interventions (HDS(C)S.2008:1.3.6)


Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes.

ARC D16.1a; D16.1b.i; D16.5a; D18.3; D18.4; E4.4 ARHSS D16.1a; D16.1b.i; D16.5a; D16.5c; D16.5f; D16.5g.i; D16.6; D18.3; D18.4



Attainment and Risk: FA

Evidence:

Two out of five files reviewed showed that care plans are not documented, and these include initial assessment, care planning and admission documentation. See CAR-1.3.3.3.

In three files out of five, care plans are developed and implemented. Interventions in these care plans are appropriate and reflective of current good practice.

The care plans of one resident has not been evaluated within the last six months. See Car 1.3.8.3.

There are appropriate links developed with other services including the local DHB and the local Hospice. Two family members and five residents and consumer survey results confirm satisfaction with the service, and family members stated that resident’s needs were being appropriately met. Discussions with the visiting hospice RN confirmed that she was happy with the care provided by the service, and stated that there are no vacant beds in the hospice. However, document review shows lack of documented evidence around interventions that are consistent with meeting the residents’ assessed needs or desired outcomes. Waverley House provides hospital level care without documented intervention. An improvement is required in this area. See Car 1.3.3.3.

D18.3 and 4- Dressing supplies are available and a treatment room is stocked for use.

Continence products are available, and resident files include continence assessments and continence products identified for day use, night use, and other management.

Continence management in-service (22 April 2013) and wound management in-service (18 November 2013) have been provided.

The RN interviewed described the referral process and related form should they require assistance from a wound specialist or continence nurse through the DHB as needed.

An internal audit of continence management was last conducted on May-2013.

The local DHB has requested further information around wound management.

Wound assessment and wound management plans are in place for four residents. The four wounds include two foot wounds and two minor wounds. All had current assessment and wound management plan in place. On interview the RN stated that there were no bed sores and all wounds are healing.

One resident was assessed for hospital level care, and a special grant was given to the Waverley House by the local DHB to continue with their services. This resident died prior to the surveillance audit. Discussions with the RN confirmed that the local DHB is responsive to individual needs of residents and supports the service with a specialist nurse input.

Criterion 1.3.6.1 (HDS(C)S.2008:1.3.6.1)

The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.

Attainment and Risk: FA

Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Standard 1.3.7: Planned Activities (HDS(C)S.2008:1.3.7)


Where specified as part of the service delivery plan for a consumer, activity requirements are appropriate to their needs, age, culture, and the setting of the service.

ARC D16.5c.iii; D16.5d ARHSS D16.5g.iii; D16.5g.iv; D16.5h



Attainment and Risk: FA

Evidence:

The activity programme is developed and coordinated by a DT who is employed 22 hours a week. The program provides a sufficient range of planned activities to maintain resident’s strengths and interests.

A range of activities are available and these include the involvement of the residents into the community. The programme reflects resident’s interest and they have choice in their level of participation. Activities include (but are not limited to): (a) outings and supervised walks, (b) exercise programmes, (c) music, (d) crafts, (e) supervised walks, (f) cooking, (g) reading, (g) games, and (h) entertainment. Resident’s social history and their preferred activities are identified on admission and these are documented in the resident’s file.

Activities are planned monthly and a copy of the activities plan is displayed on the notice board at the reception/entrance area and in the lounge.

D16.5d Individual activity plans are reviewed when care plans are reviewed.

Two relatives interviewed are satisfied by the activities programme and stated that it is appropriate for their relatives.

Due to the gated facility policy, residents need staff assistance to leave the facility. Interviews with the DT confirm that she facilitates guided walks and outings ensuring that resident’s rights to access outdoor areas and the community is provided. The DT stated that she is well supported by the staff and the management.

D16.5d Resident files reviewed identified that the individual activity plan is reviewed when at care plan review.


Criterion 1.3.7.1 (HDS(C)S.2008:1.3.7.1)

Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.

Attainment and Risk: FA

Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Standard 1.3.8: Evaluation (HDS(C)S.2008:1.3.8)


Consumers' service delivery plans are evaluated in a comprehensive and timely manner.

ARC D16.3c; D16.3d; D16.4a ARHSS D16.3c; D16.4a



Attainment and Risk: PA Low

Evidence:

Two out of five residents files sampled showed that care plans are evaluated by the RN six monthly or earlier if needed. Two of the files were the most recent admissions and were not due for review. One residents was due for care plan evaluation in February 2014 and has not been completed yet. An improvement is required. There is at least a three monthly review by the medical practitioner for medically stable residents. Staff (RN, caregivers and the DT) and family interview confirmed that evaluations are conducted by the RN with input from the resident, family, care staff, DT and general practitioner. On the day of audit, GP was not available for interview.

Changes in health status are documented in progress notes and by use of short term care plans. Short term care plans are used widely by the RN. For example, one resident requiring reduced dose of insulin had short term care plan. Another resident with infection and wound also had short term care plans.

Family are notified of any changes in resident's condition and this is documented in the resident’s file. Document review evidenced referral letters to specialists and other health professionals.

Two relatives confirm that they are involved in the review of their relatives care.

D16.3c: Three out of five files reviewed showed that all initial short term care plans were developed and documented by the RN within three weeks of admission and care is evaluated by the RN over the initial three weeks of the resident's admission. A long term care plan is developed within three weeks of admission. Two files reviewed had no initial care planning at all. See Car 1.3.3.3.

D16.3k Short term care plans are in use for changes in health status e.g. infections, wounds, skin tears, changes in health status.

Criterion 1.3.8.2 (HDS(C)S.2008:1.3.8.2)

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.

Attainment and Risk: PA Low

Evidence:

Two resident’s files out of five had documented care plan evaluations that are consumer focused and indicate degree of achievements against interventions.



Finding:

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.



Corrective Action:

Ensure that care plan evaluations are completed at least six monthly.



Timeframe (days): 90 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.8.3 (HDS(C)S.2008:1.3.8.3)

Where progress is different from expected, the service responds by initiating changes to the service delivery plan.

Attainment and Risk: FA

Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Standard 1.3.9: Referral To Other Health And Disability Services (Internal And External) (HDS(C)S.2008:1.3.9)


Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet consumer choice/needs.

ARC D16.4c; D16.4d; D20.1; D20.4 ARHSS D16.4c; D16.4d; D20.1; D20.4



Attainment and Risk: FA

Evidence:

The service facilitates access to other services (medical and non-medical) and where access occurs referral documentation is maintained. This is evidenced in one resident who has been referred for hospital level care assessment. Residents' and or their family/whanau are involved as appropriate when referral to another service occurs. D16.4c; The service provided an example of where a residents condition had changed and the resident was reassessed for a higher level of care. However one resident was admitted for palliative care but there is lack of documented evidence around notification to the needs assessment service coordination agency/ Options Hawke’s Bay. See CAR-1.3.3.3.

D 20.1 Discussions with the RN identified that the service has access to the needs assessment service co-ordination agency, primary care and district nursing, specialist nurse advisors from the DHB, specialist medical services (including the older persons mental health and allied health service, Hawke's Bay DHB) and laboratory services, and the local hospice.

Waverley House continued to be operated as a locked facility and there is digital lock on the front door. Since the previous audit, the policy has been updated. The policy is discussed with the EPOA or resident on admission and a consent is obtained. Eight files are reviewed to test if all consent are signed and dated. This was evidenced in all eight files. On the day of the audit, visitors and family members are able to use the access code and leave and enter the building as they wished. The auditor did not observed any resident who made an attempt to go out of the building. Residents are regularly taken for a walk with staff assistance. Review of these files and the staff interview confirmed that there are no residents reside in Waverley House that required re assessment due to increase needs for a secure environment for safety. Therefore required corrective action from the previous audit has been addressed.


Criterion 1.3.9.1 (HDS(C)S.2008:1.3.9.1)

Consumers are given the choice and advised of their options to access other health and disability services where indicated or requested. A record of this process is maintained.

Attainment and Risk: FA

Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Standard 1.3.12: Medicine Management (HDS(C)S.2008:1.3.12)


Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.

ARC D1.1g; D15.3c; D16.5e.i.2; D18.2; D19.2d ARHSS D1.1g; D15.3g; D16.5i..i.2; D18.2; D19.2d



Attainment and Risk: PA High

Evidence:

Medication policies and procedures cover medication prescribing, dispensing, administration, review, storage, disposal and medication reconciliation. Waverley House uses a robotic medication management system. Robotic rolls are delivered monthly in fortnightly rolls. The RN reconciles medicines on delivery, and the pharmacist is informed of any discrepancies. Medication charts have photographic identification. All care staff are required to be competent to administer medicines due to the need to have an effective roster and the RN oversees this process. Medicines are stored in a locked storage area in a corridor opposite the RN's office. Controlled drugs are stored in a locked safe in a locked cupboard within that locked area. Controlled medications are checked weekly and this is an improvement since the previous audit. .Any medications requiring refrigeration are kept in a separate covered box in the fridge in the kitchen. Fridge temperature recordings are documented. On the day of audit there are no residents self-administering medicines. The audit identified several issues that are considered high risk.

D16.5.e.i.2; GPs review residents three monthly or more frequently and sign their respective medication chart. This is evidenced in nine out of 10 medication charts. See CAR- 1.3.12.1.

Criterion 1.3.12.1 (HDS(C)S.2008:1.3.12.1)

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.

Attainment and Risk: PA High

Evidence:

There are policies and processes that describe medication management that align with accepted guidelines. Waverley House uses a robotic system and the medications are checked on arrival from the pharmacy by the RN. Any mistakes by the pharmacy are regarded as an incident and reported back to the Pharmacy. Medicines are stored in a locked storage area in a corridor opposite the RN's office. Controlled drugs are stored in a locked safe in a locked cupboard within that locked area. Controlled medications are checked weekly and this is an improvement since the previous audit. Any medications requiring refrigeration are kept in a separate covered box in the fridge in the kitchen. Fridge temperature monitoring occurs. Medication charts record prescribed medications by residents’ general practitioner; these are kept in the medication folders. Medication administration sheets have an identification photo of the individual resident. Signing sheets are in place for packed medication, short term and prn medication. Allergies are identified in residents’ medication charts.



Finding:

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 XXXXX 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 paracetamol was instructed to be administered twice a day as a regular medication. This happened on two occasions. In another incident, laxol 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 XXXXX was changed. The prescriber crossed over the dose and re-wrote the new dose next to it. 15 units XXXXX were charted at bed time. It was crossed over and the new dose was re-written as 12 units at dinner time. 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 insulin 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 XXXXX but kept in the drug cabinet.

k). On one chart (respite care resident) – a medication XXXXXX 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



Corrective Action:

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.



Timeframe (days): 7 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.12.3 (HDS(C)S.2008:1.3.12.3)

Service providers responsible for medicine management are competent to perform the function for each stage they manage.

Attainment and Risk: PA Moderate

Evidence:

All care staff are required to be competent to administer medicines. Staff who administer medication complete medication competencies yearly. Six staff files reviewed showed that one staff member had current medication competency dated January 2014.



Finding:

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.



Corrective Action:

Ensure that staff administer medication have current medication competency.



Timeframe (days): 30 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.12.5 (HDS(C)S.2008:1.3.12.5)

The facilitation of safe self-administration of medicines by consumers where appropriate.

Attainment and Risk: FA

Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.12.6 (HDS(C)S.2008:1.3.12.6)

Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.

Attainment and Risk: FA

Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Standard 1.3.13: Nutrition, Safe Food, And Fluid Management (HDS(C)S.2008:1.3.13)


A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.

ARC D1.1a; D15.2b; D19.2c; E3.3f ARHSS D1.1a; D15.2b; D15.2f; D19.2c



Attainment and Risk: PA Low

Evidence:

Food service policies and procedures are appropriate to the service setting. A dietary profile is completed on admission by the RN. Two cooks and caregivers are advised of resident’s likes and dislikes and any special dietary needs or allergies. There is a small but functional kitchen and two cooks are employed 07.30-13.00 hrs daily on a 'four days on-four days off' roster.

Additional snacks are available for residents when required. Residents are offered fluids throughout the day. Residents' files sampled demonstrate monitoring of individual resident's weight. Food in the kitchen and storage areas are dated, labelled and rotated. Food in the fridges and freezers are stored correctly, dated and covered. Fridge and freezer temperatures are checked and recorded. There is a rotating four weekly seasonal menu. There has been no dietitian input in their menu since 2008.

Two relatives and five residents confirm that they are satisfied with the meal service. Lunch meals sighted during the audit are observed to be well presented. Food services audit is completed in 2014 July and shows satisfaction with meal services.

D19.2 Staff have been trained in safe food handling.

Criterion 1.3.13.1 (HDS(C)S.2008:1.3.13.1)

Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.

Attainment and Risk: PA Low

Evidence:

There is a rotating four weekly seasonal menu.



Finding:

Dietitian input to the menu has not been obtained since 2008.



Corrective Action:

Ensure that a dietitian input to the menu is obtained.



Timeframe (days): 180 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.13.2 (HDS(C)S.2008:1.3.13.2)

Consumers who have additional or modified nutritional requirements or special diets have these needs met.

Attainment and Risk: FA

Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.13.5 (HDS(C)S.2008:1.3.13.5)

All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.

Attainment and Risk: FA

Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)



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