Audit Tips – Common findings in audits

Audits in the aged residential care sector in New Zealand are assessed against their ability to comply with a raft of legislation, standards and contractual requirements.

Below are common findings which continue to be reported on during audits:

 

Criteria

Gaps in meeting full compliance

Consumer Rights

– 1.1

·         Complaints management processes not completed as per                   requirements. Eg; not being logged on the complaints                         register, time-frames not being met, lack of evidence of                     resolution.

Organisational Management

– 1.2

·         Not completing internal audits

·         Not evidencing completion of regular meetings

·         Corrective action plans not being developed or completed

·         Lack evidence of investigation

·         Lack evidence of family notifications of adverse events

·         Lack evidence of reference checks at time of employing new             staff

·         Lack of 1st Aid certified staff member on each duty in each                 work area – this must consider the size, and layout of your                   building.

·         No signed employment agreement or job description

·         Lack evidence of timely completion of orientation

·         Annual appraisals not completed for all staff

Service Delivery

– 1.3

·         Lack of timely clinical assessment

·         Lack of assessment and care-planning related to behaviours               of concern (challenging behaviours)

·         Lack of evidence in progress notes of Registered Nurse input

·         Lack of evidence in progress notes of interventions from long             term care plan

·         Lack of evidence of family / residents input

·         Lack of evidence of outcomes from clinical assessments                     (including InterRai) being used to inform the care plan

·         Transcribing of medications in care plans

·         Doctor’s instructions in medical notes not followed /                             implemented

·         Wound assessment chart not updated as per wound care plan

·         Neurological observations not completed following falls                      where there was a possibility of the resident having sustained             a head injury

·         GP reviews not recorded at time-frames determined in ARRC

·         Lack of evidence of RN acting on caregivers reporting of                     adverse health symptoms in progress notes.

Safe and Appropriate Environment

– 1.4

·         Lack of evidence of medical calibration of equipment

·         Hoists not checked and verified as fit for use.

·         Surfaces unable to be cleaned adequately

·         Non labelled or decanted chemicals

·         Lack of evidence of hot water temperatures not exceeding 45            degrees

 

Restraint minimisation and safe practice – 2.0

·         No evidence of enabler monitoring

·         Lack of evidence of incomplete restraint register.

Infection prevention and control

– 3.0

·         Infection control nurse in care facilities who have not                           completed training in infection prevention and control and                  therefore cannot demonstrate relevant knowledge on which              to base practice and monitor staff performance.

·         Not all infections are noted on the infection register. Your                    policy and procedure should include the internationally                      recognised definitions for infections on which to base your                  monitoring.  For those of you using the HCSL policies and                   procedures, these definitions are noted within the Anti-                     microbial  Policy – document code IC1.

 

 

Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of your service.

For more assistance with this contact us.

Are your staff increasing risk of cross infection?

Cardigans – a potential vector of infection?

Each winter cardigans or long sleeved tops under uniform tunics appear as part of clothing worn by carers, nurses and other staff providing resident care.  Does this practice increase the risk of cross infection?

There are certainly studies that demonstrate that uniforms become contaminated with potential pathogenic organisms including Staphylococcus aureus, Clostridium difficile and Norovirus[1]. It is more difficult to find evidence that links contaminated uniforms with the transmission of pathogens to patients and residents.

Most contamination occurs in areas of greatest hand contact such as pockets and cuffs[2], which may the cause the wearer to re-contaminate their cleaned hands. Long sleeves may also become contaminated with bodily fluids, which then directly contaminate another resident through direct hands on care. This would be a great way to spread around those multi-drug resistant organisms that live in the bowel, such as ESBL, VRE and CRE!

The biggest risk of wearing long sleeves when delivering care involving patient contact is that hand hygiene cannot be carried out effectively. Anyone who has been taught hand washing using the Glitterbug gel and UV light will remember how the wrists were often left glowing, demonstrating that your wrists also get contaminated and need cleaning. In many healthcare facilities across the world, a ‘Bare Below the Elbows’ policy is used to ensure that effective hand hygiene is undertaken. This applies to the use of an alcohol based hand rub or gel, as well as washing with soap and water.

So the next time that you put your cardigan on or come to work with a long-sleeved top, remember that, prior to any patient contact remove the cardigan or roll up your sleeves and perform hand hygiene.

[1] Mitchell et al. Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature. Journal of Hospital Infection, 2015 Aug;90(4):285-92

[2]Loh et al. Bacterial flora on the white coats of medical students. Journal of Hospital Infection,  2000 May;45(1):65-8.

 

Contributed by:

Ruth Barratt

Infection Prevention & Control Advisor

infectprevent@gmail.com

Falls – When is a fall not a fall?

Is a slip off a chair or off the side of the bed onto the floor a fall?  Is a ‘controlled lowering’ by a staff member of a resident to the floor a fall?

When recording adverse events such as falls, it’s important for the purposes of consistent reporting and bench-marking that the same definition is used to define a ‘fall’.  We suggest using the definition provided by the World Health Organisation (WHO) which states “A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.”  The WHO falls prevention guidelines also report that “Globally, falls are a major public health problem. An estimated 424 000 fatal falls occur each year, making it the second leading cause of unintentional injury death, after road traffic injuries.”  

Working in aged care related services means you are interacting on a daily basis with those in the high risk category for falls. WHO also report for example, in the United States of America, 20–30% of older people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas. The Health Quality and Safety Commission New Zealand reportfor every fall in hospital, there are five in aged residential care and another 40 at home and in the community. Between 2010 and 2012, a total of 200 people fell while in hospital care and broke their hips.

The HCSL QA online bench-marking includes tracking of falls and falls related injuries so educating your staff to become familiar with the definition is important in ensuring data collected is accurate. Accurate data measurements also allow you to be aware of your start point for quality improvement projects which can then be measured at the end of a project to measure the degree of improvement.

In answer to the questions posed at the start of this article, if we apply the WHO definition, then both should be classified as falls.  For those of you using the HCSL policy and procedure system, refer to the Falls Prevention Programme (document CS19) for more information on falls prevention.

Pressure Injuries – ACC may be able to help

‘Pressure injury’ according to ACC can be classified in some instances as a ‘treatment related injury’ and therefore you may have the option of gaining support / assistance from ACC in relation to treatment of the pressure injury. In their 2011 fact-sheet, ACC noted “Pressure areas are a significant source of treatment injury claims and impact on both patient morbidity and mortality (1). Between July 2005 and March 2011, ACC accepted 506 claims for pressure areas, and notified 45 as adverse events to the Ministry of Health”.

As pressure injuries are a key focus for Ministry of Health (MoH) this year, auditors will be looking closely at the documentation around identification, management, treatment / care planning and evaluation of these events. Ensure you have comprehensive evidence of your clinical management processes.

Also remember when you log a pressure injury into the adverse event reporting system, you include the stage of the pressure injury. In the HCSL QA online system click ‘pressure injury’ in the ‘type of event’ box and then in the box directly under that, you can record the additional detail of the stage of the pressure injury.

The required MoH notification forms can be found here.  You will need the resident GP to complete a ACC45 form. Then contact ACC and rather than asking for what you want, ask what they can do to help. If you ask first, you may be missing out on something they could have provided access to.

For more information on seeking support contact Assistant ACC directly or the ACC Contracts Manager – CDHB Email: Leanne.davie@cdhb.health.nz

Bench-marking – Aged Residential Care

This New Zealand designed web based (on-line / in-the-cloud) Bench-marking and quality management system from Healthcare Compliance Solutions Ltd allows you to:

  • Bench-mark in real-time – specific to resident type, event type, date and time of day.
  • Have automated default reports to save you time analysing your data trends and patterns
  • Drill down into your data easily to identify opportunities for continuous improvement
  • Complete your internal audits online and have the corrective actions auto-populate into a corrective action log
  • Log and manage adverse events
  • Bench-marking of adverse events against other aged care providers
  • Support evidencing an active Health & Safety programme is in place
  • Log and manage infections
  • Bench-marking of infections against other aged care providers
  • Log and manage your complaints with time-frame, investigation and response prompts
  • Dashboard view options for level of care and any chosen 3 monthly time-frame review
  • Dashboard view option of adverse events or infections
  • Logs (event registers) appear with individual events in one colour when open and change to another colour when the event is closed. This allows you to see quickly the status of events. 
  • Use in conjunction with your current policies / procedures or update to the HCSL site specific created policies and procedures. 

Your organisation policies and procedures and related documents (if created by HCSL) are also accessible to the lower left of the screen for remote anytime, anywhere access.  The search option on the policies and procedures in addition to precise indexing and coding of documents makes it very quick and easy to locate information for staff to reference.

This is what Rhonda Sherriff, NZACA Clinical Advisor says about using the HCSL QA system:

“I am very happy to endorse your system as the information is invaluable for CNMs to analyse the data/information and make informed decisions on best practice and innovation to decrease hazards, improve outcomes, and mitigating factors for resident welfare. I’m pleased you are delving into the data to the level you are, as it’s time saving for sites in many respects, and so easy to dice and slice the information to get the trends. CNM’s used to spend hours just writing up the collective information before the analysis, so hugely time saving”

To view a brief video explanation of the system click here.

To find out more contact us here.

Person-centered Care depends on your recruitment processes

On a recent trip to Cambodia and Singapore I visited the older members of the community where they were being cared for and spend their final days.  In Cambodia, where there are no formal aged care services; I found the older members of their communities being care for by each other in either family or Buddhist temple settings.  The choice is often made by the oldest members of families in Cambodian society to leave home and move into a temple and take on the lifestyle of a Buddhist Monk or Nun.

I was honoured to have had the opportunity to visit these folk and talk with them about their lives and experiences. I asked them if they missed anything about their previous life.  The answer when I’ve asked that same question of elder folk in New Zealand has resulted in a long list. These gentle folk smiled broadly at me and told me no, there was not a single thing they missed. Their families still came to visit them. It seemed that was all they needed from life as it was!

In caring for each other these ladies practiced the principles of person-centered care. They were not familiar with the term, were not trained nurses and were not carers who had received formal training. Never the less, they provided care as needed by those receiving it. This was about social housing and accommodation rather than a focus on infirmity, disability or ill health.

On my visit to a nursing home in Singapore, it was inspiring to see the elder ladies sewing staff uniforms and other elder men and women preparing vegetables. These would become meals of the children crèche down the road. These folk talked as they worked together. They were connecting and contributing. Making a difference. They were needed and had value.  They held a high status within their community.

In the Singapore Nursing home residents lived in the nursing home in 8 bed units, men segregated from the woman. The sense of connection between residents however was obvious from the numbers of people I saw sitting beside other residents’ beds talking with them, interacting together and chatting as they worked.

There were trained nurses and the Welfare Officer who was a fountain of knowledge talked about person-centered care. The residents’ activities programme was full and could have easily been transferable to any NZ residential care facility.

The terms used were the same as ours but as I looked around I could see the implementation of person-centered care was very different from our interpretation of that type of service. Residents were certainly engaged, appeared happy and well care for.

What struck me however was how different our understanding of the term ‘person centered care’ is and how a society’s culture or organisational policies can mean our practice is very different.

This is an important factor to remember when recruiting staff that have been trained and work in other countries. When you describe something to an applicant you’re recruiting and they say they understand the concept, does it necessarily mean you have the same understanding. The picture in your mind of what the outcome will look like may be very different to their mind-view?  Sometimes it pays to ask more questions!

Quality Management Systems

The below question and answer were published in the New Zealand Aged Care Association industry ‘In-Touch’ newsletter (19th February 2016).

Question: A member asks “if we purchase a comprehensive quality management system from a provider how assured are we that the system will meet full compliance, come certification and surveillance audit time, as requirements and compliance expectations change frequently?

NZACA Clinical Advisor Answer: “You should be purchasing a complete quality management system that will comply with the Health and Disability Standards specifications, health and safety requirements and meet DHB/ARRC contractual requirements.

The provider of the system would normally initially tailor the full quality management package to reflect accurately the site specifications, H.R. component, and best practice guidelines, after consultation with the owner and management on site. These documents need to be site specific. The provider will normally contract to the site, which sets out obligations between the provider and the site management.

The contract will include the full review and updates of policies and procedures on a bi-annual basis, unless specified more frequently, to keep documents accurate and reflective of best practice. There may be an educational element provided within the contract as well, to benefit staff knowledge and skills. There is normally a good document control system in place and cross referencing of information where required.

Quality management systems are reliant on the skills and knowledge of the site personnel working with them, the way the system is managed and the outcomes/reviews, content and information extricated from the use of the system to improve quality care provision/outputs. The documentation system is reflective of the people using them, and the depth to which documentation and information is created, analysed and utilised for improvements.

Auditors on site rely on the provision of robust up-to-date policies and site adherence to them. Partial attainments can sometimes result from staff deviating from, or not following, their sites actual policies or processes as outlined in their quality management system.”

Where can you get such a system? 

Here at Healthcare Compliance Solutions Ltd we provide the services described above and noted as being optimal for achieving excellence in care and audit outcomes. 

Request a no obligation consultation here.  

 

Medication Management Audit Tips

 

 Medication management relates to section 1.3.12 of the Health and Disability Services Standards and referred to in section D5.4 of the ARRC.  There are key reference documents which provide reference at facility level which should be used in conjunction and addition to your organisation policies and procedures.  These reference documents are (first two are key for residential care):

 

Medication errors of any type, when reporting through the audit process to MoH HealthCert as part of your audit, will receive a higher ‘weighting’ than other partial or non-attainments.  Even a single signature missing off an administration signing sheet may come into this category and mean your audit outcome is diminished.  Below are common errors which continue to be made:

Aspect of medication management 

Common Errors 

Medication charts

Not dated

Not signed by the prescriber

Not signed by the General Practitioner or Nurse Practitioner at each review (3 monthly)

Not legible

Allergies not documented (or inconsistent with other resident documents)

Transcribing on medication charts or PRN signing sheets

PRN medication charting does not include ‘indication for use’

Medication order does not include time, dose, frequency, route, type etc

Signing sheets

Missed signatures on the signing sheets

Only one signature (instead of two) on controlled drug administration records and register

PRN medication not signed for accurately

Self-medicating residents

Competency to verify self-medication not signed by prescriber

Competency for self-medication not signed as having been reviewed by prescriber (3 monthly)

Staff verification of self-medicating occurred not recorded on a shift by shift basis (as relevant to the individual residents medication order)

Not retaining a current list of all medication ordered for self-medicating residents

Storage

Medication not securely stored (also see ARRC D15.3(c)

Controlled drugs not entered accurately into Controlled Drug Register (at time of supply or return to pharmacy)

Controlled drugs not stored in locked cabinet in locked room

Drug trolley left in common areas unlocked

Expired medication continue to be stored on site (should be returned to pharmacy)

Medication for resident who has been discharge or deceased remain on site

Medication fridge temperature not monitored / recorded

Labels on medication containers not clear / legible

Identification of resident

Photograph not representative of current presentation of resident (photograph should be colour)

Photograph of residents not validated regularly

Medication errors

Not reported

Not managed (through an adverse event management process to ensure identification of contributing factor and preventive measures).

Competency

All staff (including Registered Nurses and Enrolled Nurses) involved in medication administration must have first successfully completed a medication competency

Annual review of medication competencies

If you’re uncertain about the competency of a particular staff member, do not be tempted to sign them off and monitor.  The risk is too high for the residents and your organisation.  Medication errors can be classified as ‘sub-standard care’ and due to the possible consequences, are at least a moderate risk.

Remember when changing staff around, the key priority is do you have a medication competent staff member on each duty and if controlled drugs are being administered, you need a minimum of two medication competent staff rostered on each duty.  Registered Nurses cannot be leaving the ‘hospital’ area of the facility to administer medication in other areas as this leaves the hospital residents vulnerable so this also needs to be factored into your rostering.  Refer to the Aged Related Residential Care Contract (ARRC) for further information.

Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of medication management.

MRSA or ESBL positive staff or residents – what to do, changing times

MRSA was first isolated in NZ in 1975, remained at extremely low levels over the next 10 years (0.05% of 2077 surveyed Staphylococcus aureus isolates nationally in 1982). But from the 1990’s onwards the incidence of various strains of MRSA has steadily increased in both hospitals, rest homes and the community.

Most of us carry Staph aureus as part of our normal skin flora.  When we have a cut, wound  or other compromised skin integrity (e.g. infected dermatitis/eczema) some of our normal flora can increase in numbers to cause what we recognise as a clinical infection.

i.e. we catch this Staph aureus infection from our own normal flora

Community laboratory data now shows that 5 out of every 100  Staph aureus  infections in the South Island,  12 out of every 100 in the Auckland region,  are now MRSA

i.e. MRSA is now endemic in the population,  so trying to isolate those with MRSA or remove it from those who are carriers by ‘decolonisation’ (e.g. chlorhexidine body washes and mupiricin) is a wasted effort, and can in fact be counterproductive – toxicity, promotes antibiotic resistance, stigmatisation, isolating residents is generally shown to produce worse clinical outcomes.  Isolation is required for some infectious diseases which MRSA is not.

Resident/patient with MRSA – use good Standard Precautions (hand hygiene).  Cover any infected cuts or wounds as per normal.  Plus Contact Precautions (glove/gown) as you normally would if providing wound care and splashing or direct skin or uniform contact possible.

Staff member with MRSA – again no special precautions are generally required and ‘decolonisation’ is not indicated.  Good Standard Precautions (hand hygiene – alcohol hand rubs or liquid soap and water both work well).

We should always aim to prevent any cross infections of any organisms, susceptible or resistant.

Good ongoing environmental and equipment cleaning and hygiene should be maintained routinely in the facility, regardless of any known MRSA or other resistant organisms  (e.g. ESBL).

Additional Facts

  • Our total combined use of antibiotics has bred or created these resistant bacteria – are we doing all we can to reduce any over use of antibiotics? g. UTI’s are commonly ‘over treated’ on a positive dipstick result rather than clear clinical symptoms
  • Any known positive MRSA (or ESBL) only represents the tip of the iceberg – a known positive person is an indicator only of a much larger issue, there will be many more unknowns. So, like blood and body fluids, it is best to think any one of us – staff residents and patients – could be positive at any time because we not uncommonly will be but seldom be aware of it
  • MRSA, ESBL, VRE carriers – the good news is 9 times out of 10 we spontaneously lose our carriage or colonisation of these resistant bacteria in 1-12 months when we happen to be carriers and do not use antimicrobials, and usually we will not know when we are carriers, but temporary carriage is likely on staff several times over in a 5-10 year period
  • ESBL (extended spectrum beta lactamase) is increasing similarly to MRSA, but started a few years later. Its primary reservoir source is the bowel not the skin
  • Staph aureus itself (the susceptible form MSSA and the more resistant form MRSA) generally have equal pathogenic potential but are generally normal flora also
  • Each one of us is made up of 10 trillion tissue cells and 90 trillion bacteria  e. ‘your bugs are my bugs’ – we cannot but help share our microbes by touch, shedding skin, etc but we must actively reduce this sharing by good Standard Precautions on all by all

Our combined total use of antibiotics continues to create ever more microbial resistance.

Good hand hygiene and cough containment Standard Precaution practice coupled with thorough cleaning of equipment and the environment will ensure there is a lower risk of transmission and environmental contamination of our shared microbes – the resistant and susceptible forms.

Article shared with the kind permission of:

Author: Ben Harris – Microbiologist – Southern Community Laboratories (2015) 

 

 

 

Taking things for granted….

I ate the best crispest, crunchiest, juiciest, rosiest, sweetest most marvellous apple while I was driving home last night after attending a seminar. I had put it in my bag earlier for just such an occasion and it really was the very best apple.

You might be wondering why I’m writing about eating an apple. Well the point is I can eat an apple. I can eat an apple while driving a car. No-one should drink and drive and we are not allowed to text and drive but eating an apple while driving is still allowed.

The reason it was good to eat this most marvellous apple was that in order to eat it I first had to achieve a whole range of things. I had to have the money to pay for this crunchy crisp apple which confirms I have the financial reserves to not only pay for the petrol and maintenance for my car but also to pay for this beautiful rosy apple. I had to also remember that I liked apples along with remembering where the supermarket was to buy that most marvellous apple. I then had to recall where I’d parked my car and have the mental competence to get myself and my car and my apple out of the car-park and heading for home.

This all takes having an intact mind so I find it rather encouraging and reassuring that my mind seems to be working just fine.
To be able to eat this delicious thirst quenching juicy apple I had to have physical strength to drive my car and walk into the shop, buy the apple and walk with ease back to my car without getting short of breath in order to drive home. I had to have the muscular strength in my legs to walk, use the foot controls in my car with ease and have the physical reactions to stop in a hurry if I had to. All this being achieved while enjoying a gift of natures food, my wonderful apple. The hand dexterity needed to hold and manoeuvre that apple so I could bite the piece I wanted while steering the car was also something I take for granted. I realise I take for granted having healthy teeth to munch and crunch that beautiful apple. This all confirms my body and mind seem to still be functioning with strength and ease which I am very grateful for.

As I savoured every mouth full of this delectable apple while driving home tonight I wondered if when I’m 80 or 90 years old I will still be able to do this most enjoyable feat. I thought of all the things that must function for me to buy apples year after year. Will I have the ability to drive my car and walk into the supermarket and pick the nicest looking apple, pay for it and eat it with my natural teeth? Oh I do hope so.

To increase my odds of repeating this enjoyable drive home devouring delicious mouth full by delicious mouth full of apple, I decide I will need to take good care of myself. I will need to make sure I keep up my physical strength through regular exercise and eat a good diet to maintain a healthy weight. I will need to look after my eyesight with regular eye checks. I will remember to take regular visits to the dental hygienist and look after my teeth. I will manage my finances and enjoy reading books, socialising and learning new things to keep my mind active. And yes, I will continue to hope that with all the right self-cares and a bit of luck, when I am 80 or 90 years old I will be able to go to the supermarket to pick out the very best apple.