• Home unable to demonstrate that care and services are tailored to resident needs and choices.
• Management unable to describe best practice at the home and how this is provided through policies, procedures and assessment tools.
• Insufficient systems for identifying consumer risks and deterioration.
• Consumers not being reassessed by the speech pathologist/dietitian in line with identified needs; staff with no knowledge of the international dietary dysphasia standardisation initiative levels and consumers not reassessed under the new system.
• Management of significant weight loss – not following policy and not acting in a timely manner.
• Management of pressure injuries – gaps in wound care regimes; lack of timely referrals to external consultants.
• Management of high-risk respite consumers – unclear how they are identified by staff and supported and provided with referral to key agencies as required, including on discharge.
• The Psychotropic Self-Assessment Record - poor documentation and management of this document. Homes need to ensure they have systems in place to ensure the currency of this document including regular review and updating (June 2019 to present).
• No evidence of risk assessments for restraints; alternatives not being documented as per legislation; inappropriate use of emergency restraint processes; RNs not aware of restraint legislation; GPs not reviewing restraint documentation; consumer not monitored when restraint or restrictive practice is being used e.g. bed rails in place.
• Behaviour Management – poor use of external agencies to assist in the management of behaviours, including not referring to DSA.
• Infection control management – no vaccination listing for both consumers and staff; no information provided to consumers and staff for informed consent or no evidence of consent.
• No systems to support the comprehensive review of consumers returning from hospital and actioning of their changed needs. This includes lack of clear documentation for demonstrating information provided to the medical practitioner, review of assessments and care plans; and follow up of discharge requirements and referrals, as required.
• Antimicrobial stewardship – limited examples of goal setting and training of workforce, in particular RNs, as well as limited communication to consumers and representatives.
• Progress notes not adequately:
o documenting other stakeholders involved in care, including their role in care planning and assessment o defining risk issues and alternative management strategies.
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