With the introduction of the Food Act 2014and the requirement for most aged care facilities to have registered their food control plan (FCP) by March 2018, I thought I would write this article on a common kitchen practice that will require review.
FCP’s are included in the policy and procedure documentation provided by HCSL specifically designed for residential care facilities.
In many facilities the main meal is served in the middle of the day and the tea meal served at night. The main cook of the day will prepare the tea meal earlier in the afternoon, and then finish his or her shift. The tea meal will be reheated by the afternoon staff and served to the residents.
The process of cooking, cooling and reheating requires careful control of the food safety risk. Many tea options are protein or carbohydrate based; macaroni cheese, egg dishes, savoury mince, chicken options – all of which are high risk foods for bacteria growth.
Foods need to be cooled quickly to avoid time and temperature abuse, which may allow bacteria growth. The guidelines state that when cooling hot cooked foods, the food must cool to at least 21° within the first two hours, and then cool to below 5° in four more hours. Overall, the food must be out of the danger zone (between 5°C and 60°C) within six hours.
A functioning chiller should allow cooked foods to cool within this timeframe. Using domestic fridges that are overcrowded, may mean the cooling guidelines are not met. Using shallow dishes rather than large deep dishes will also allow foods to cool faster.
The food control plan will specify the process the site kitchen must follow with regards to cooling of cooked food. Temperatures during cooling will need to be checked and recorded to ensure the time / temperature targets are met.
Prior to serving, the food must be reheated to above 75°C.
Some sites choose to hold the prepared food hot until service. Food must be held hot at a temperature of at least 60°C, usually in a bain-marie or oven at 70°C. Any food held below 60°C for more than 2 hours, must be thrown out. Note that holding foods hot for this period of time may affect the food quality.
Main Points:
Food safety risk with cooling and reheating foods must be managed with FCP
Cool cooked food to below 21°C in 2 hours and below 5°C in 4 hours
Reheat foods to above 75°C before service
Hold hot prepared foods at 60°C or more
Document food temperatures and any corrective action
Review corrective action implementation to ensure they have been effective
Some may think the actions a little extreme but the objective was to minimise risk to others and in doing so, minimise the numbers of people (residents and staff) infected with Norovirus. The below is how one facility dealt with a norovirus outbreak recently.
Here’s how we dealt with what happened in our facility:
With the Clinical Nurse Manager on annual leave at 8.00 am on Friday 11 January the Senior RN advised the QA we had two suspected cases of vomiting and diarrhoea. At 10.00 am the Senior RN advised the QA we could have four more cases of diarrhoea.
An immediate meeting was called with management and the situation discussed. The following steps were instigated –
We immediately referred to our HCSL Safe and Appropriate Infection Control policy manual.
We decided to take the “worst case” scenario approach eg Norovirus.
We then set out an “action plan” and held a meeting at 11.00 am with all the staff present to advise the situation and actions to be taken –
Action Plan
Infection Control at DHB were advised and samples were sent for analysis
The Rest Home was put into “lock down”. The families and next of kin of all the residents were advised.
The Village residents were advised and instructions given to them on procedures to follow.
The doors between the three sections of the Rest Home were closed and staff confined to these areas only – no exceptions.
The infection log from HCSL system was immediately put into use – an RN had to sight all vomit and diarrhoea together with noting the times and dates – this information was supplied on a daily basis to DHB – this information was imperative to identify if virus was spreading, how quickly, or if it had been confined to certain areas etc.
The RNs appointed “dirty” nurses on each shift. A “clean” person was also appointed for delivering supplies around the whole rest home. Trollies were meticulously sanitised when “travelling” between these areas.
Kitchen staff were confined to the kitchen only
All residents were confined to their rooms with meals being delivered using “clean” and “dirty” trollies. This may seem extreme but the residents were agreeable to this.
Diagrams out of our policy manual were put in the Nurses Stations on how to put on PPE. Full PPE was mandatory in all “dirty” residents rooms and when serving food or drinks. Face masks were mandatory for all staff at all times – no exceptions. Full face shields were used in the laundry and any very soiled linen was disposed of as per instructions.
Hand washing and sanitising techniques were vigorously adhered to.
The cleaners were issued with “heavy duty” cleaning products and all vacuuming was banned.
Being an older Rest Home with only certain areas being air conditioned it was easy to turn off all conditioning and keep off.
Residents were encouraged to open their windows for fresh air and let in the sunlight.
Cleaning equipment was kept in the “dirty” rooms for their use.
All residents were advised to put toilet seats down prior to flushing and flush twice.
All residents and staff were reminded of hand hygiene practices and we ensured the appropriate supplies of hand washing and hand hygiene gels were available.
Communal areas in the Rest Home were closed, cleaned, sanitised and not used.
Management held a daily meeting at 9:00am to report on the up to date situation and a report was issued to the staff at 1:00pm and a daily report issued to the DHB.
The rest home was advised by DHB ON 16 January 2019 to let residents out of their rooms but stay confined to the areas of the Rest Home they lived in
On 21 January 2019 the rest home underwent a complete steam clean of carpets, drapes etc,
On 22 January 2019 we re-opened the Rest Home to visitors again.
LESSONS LEARNT
We had a total of only 4 confirmed cases of Norovirus – one in the hospital and three in the rest home. At the time the Rest Home was fully occupied (60 residents).
Follow your Policies and Procedures “to the letter”. Without the excellent information contained in our policy manual we would not have achieved the result we did as everyone had varying views on what to do. We had only one “view”.
We received congratulations from our DHB on handling this situation and receiving the outcome we did.
And of course we knew we always had the back-up of Gillian at HCSL either via email or telephone if required.
Since the emergence of residential care facilities in New Zealand, the models of care have continued to change, but are they changing fast enough? The clinical needs of residents have escalated and so the way services are provided must also reflect a change in practice to meet changing resident needs. A common theme being reported among older member of our communities is that of isolation and depression. Isolation, according to the Collins dictionary relates to separation, withdrawal, loneliness and segregation.
I was fortunate to visit Greece recently which is reputed to have a larger proportion of older adults than most other EU countries. Gerontology is derived from the Greek words geron, “old man” and -logia, “study of” so it made sense to discuss models of care with families and health care professionals including pharmacists. I discovered there are few residential care services in Greece and those that do exist are found mostly in Athens rather than the islands. Families provide the majority of care with ‘family’ being noted as the key foundation to Greek society. Grandparents are frequently living within the extended family with the younger generations and taking responsibility for caring for their grandchildren. The economy is poor and social networks are heavily relied on to provide support.
From my observations, conversations with others, and literature, the older adults of Greece are kept actively engaged in the community. They are frequently involved in running family businesses if they are not relied on for supporting the needs of their children or grandchildren. Family networks remain strong and when interviewing people about how older adults will be cared for, the automatic assumption is that family will provide that service. Dr Elizabeth Mestheneostold me that approximately 1% of their older population may well be in residential homes. There are Open Care Community centres in virtually every Local Authority which are called KAPI. There are also Help at Home services and Day care centres in some Local authorities.
The models of care and workforce capacity currently in place in New Zealand are unlikely to meet increasing demands so change is needed. The aged care sector could lead change as new models are developed, trialed and advanced. Multiple studies confirm these new models need to include holistic, consumer directed services. Not only meeting physical needs but also social connections and the opportunity to be involved in meaningful activities that contribute to others. This also includes some use of technology to support connections with others. While they are of assistance to some, there is no substitute for human connection, person to person, face to face. The experience of ageing, social network supports, funding models and the context in which care and support are provided certainly differ from country to country.
In New Zealand residential care settings we have activities / recreational programmes which support inclusion and engagement. Being involved in meaningful activities are also key factors in contributing to a sense of well-being. I observed older adults in Greece undertaking meaningful activities in the community like feeding the communal cats of Kos or looking after grandchildren, continuing to run a second hand open-air shop to add to the family income or playing games with friends games. Groups of older men often congregated outside cafes for conversation, coffee and playing cards or board games. A Menzshedstory reflects on how one New Zealand community are attempting to address the gap ageing can create in the life of some men. While funding is different in NZ to Greece and the family network is more often scattered geographically in New Zealand, there remains more opportunity to include community. The care setting could also be enhanced more by reflecting the smaller numbers of people we are used to living with in the family home, rather than the larger numbers in some care facilities. A model that more closely reflects the life patterns our community members have been used to, with them directing how these continue into the latter years of life with the goal of ageing in a healthy way, optimising body, brain and social networks.
Mattresses aren’t just something to lie on but if not maintained and cared for appropriately, also have the potential for causing harm.
As I travel a lot for work, I have the opportunity to test many different mattresses, all with varying degrees of comfort. This reminds me how difficult it must be for those who may be suffering painful joints to get a good night’s sleep. Appropriate mattresses are not only required to reduce pain from positioning discomfort but also reducing risk to residents. This include ensuring the mattresses are of a suitable standard and fit for purpose.
I’ve seen a number of mattresses which had hardened and torn linings and were well past being able to provide much comfort or an appropriate degree of pressure support. Some had masking tape used in an attempt to cover splits in the mattress cover. Others had holes in and were badly stained from exposure to body substances. As the residents in care are becoming frailer, with increasing acuity, the need for ensuring appropriate pressure support is crucial to preventing pressure injuries, maintaining comfort and maximizing the opportunity for good sleep.
There is the potential for old and in poor condition mattresses to be a potential source for infection transmission. For those of you operating newer facilities, this may not yet be an issue. For older facilities, part of stock and resource control should include mattress stock checks to verify they are in fact still fit for use. When conducting checks, determine the mix of mattress types you have and speak with your supplier about a replacement programme should this be necessary. As mattresses differ, so do beds and it’s important to make sure the mattress you use is appropriate for the particular bed type and size.
When reviewing your mattress stocks and purchasing new mattresses you might like to think about the following factors:
Only purchase from reputable suppliers. Review the manufacturer’s instructions for use to ensure they include verification of cleaning instructions and ask about preventative maintenance. This may include staffing training e.g. via the use of online training videos or instruction booklets.
Make sure you record the date of purchase and do your best to track each mattress and pillow to maximize warranties and make plans for replacement. Add the item to the facility cleaning schedules for regular cleaning and drying of exterior surfaces which should be durable, water-repellent and quick drying. They should also be seamless, if possible. When there are seams or edges, much sure these are situated away from resident skin contact to prevent absorption of liquid into interior and increased friction.
All seams must be tightly closed and sealed. Masking or packaging tape is not appropriate for sealing. When mattresses become worn and tear, you might like to have a supplier representative review to see what options are available for repair or replacement.
When reviewing the condition of mattresses, inspect all mattress surfaces, covers, seams and zippers for proper function and damage including wear, tears, splits, cracks, punctures, permanent odours and stains. If visible contamination from body substances are present, determine appropriate steps (eg. replacement or repair).
To support longevity of mattresses, remind staff not to place any furniture or sharp objects on mattresses. Protect the mattress with mattress protectors only if advised by the supplier this is appropriate. A number of pressure support functions in mattresses may be adversely impacted by the use of additional mattress coverings to do check.
Cleaning and disinfection must be considered in relation to mattresses, covers, wedges, cushions and pillows which are all classified as non-critical medical devices. Clean and low-level disinfect according to the manufacturer’s instructions between different resident use and when visibly soiled. Some mattress covers are removable for laundering so remember to verify which ones can be cleaned separately.
Remove damaged or stained items from service and report these in your maintenance book or to the Manager. Follow manufacturer’s instructions for use and disposal of damaged mattresses, covers, and pillows, and in accordance with infection prevention and control guidelines.
Ensure when using alternating therapy type mattresses that there is a process in place for a shift by shift verification that the pressure is maintained at the current level for the individual resident utilizing that mattress. If you plan to use an air alternating topper pad on a mattress, ensure it’s suitable for the mattress as depending on heights and size, it may not be appropriate.
Harm prevention can also be supported with advances in technology such as Pressure Monitoring sensing devices to ensure appropriate pressure distribution. I’m not aware of anyone who can rent or lease out Pressure Mappers in NZ. However Cubro have one that they can bring onsite to facilities for training and education. Make contact with your supplier to see if they can assist if this could be useful for you.
Also remember that other devices used in beds should be checked as well to ensure they are still safe and appropriate for use eg; wedges, rolls, pillows, seat cushions, mattress covers (where these are appropriate for use),bed sensor monitoring pads. For reading on how to choose the best mattress option for your needs go here.
The Lead Auditor tells us she cannot see we have any corrective actions to complete!
Also she acknowledged a CI from one of the Quality Improvements I completed. She was very impressed with the Quality and risk management systems via your Policies and procedures and says we are using your systems to the max.
Well, where would we be without your Policy and Procedures, they are great to work with – thank you.
Empathy and perspective are two concepts well known Leadership author Simon Sinek speaks about in relation to leaders. He talks about the real job of a leader as not being in-charge but taking care of those in our charge. How many leaders play the blame and shame game when things don’t go as planned? Instead how would it be if leaders in aged care services worked in accordance with a Leader’s Oath. My version is noted below as an example.
You may want to create your own for your organisation, or adopt this.
The Leader’s Oath
I focus on the betterment of this organisation above my own career needs
I focus on accountability above the need to be popular
I focus on caring for those in my charge over being in charge
I focus on clarity above certainty
I share clear expectations
I hold myself accountable for all employees poor performance including my own
I welcome respectful challenges
I will table the tough issues
I treat all interactions as though my career depends on a successful outcome
I am committed to personal and professional development
I am focused on excellence.
While the above Leadership Oath forms a focus for clinical leadership, it’s necessary to make sure your nurses are familiar with the ARRC funding agreement responsibilities for Registered Nurses. These are also clearly defined in the HCSL policies and procedures to ensure they’re integrated into practice. The ARRC includes time-frames for nursing documentation responsibilities, while the nursing council guidelines for delegation define staff delegation of staff working under the supervision of Registered Nurses are appropriate led and supported. When we refer to tabling the touch issues, one key aspect of leadership is holding staff accountable. Nurses are often not keen to hold others responsible for their conduct and performance and therefore avoid performance managing staff when performance is below the expected standard. This in turn means the service provided will be below the expected standard. If you want to provide the best care and support to those in your care, these are skills you must learn and put into daily practice. To learn more about these skills and others needed for leading a team of care and support staff, go here.
As we age, the need for spiritual care and pastoral care often come to the fore. This is particularly so as people near the end of their life. The need for comfort and peace of mind on a holistic basis. Let’s firstly lets define the difference between these two concepts.
Pastoral care is an ancient model of emotional and spiritual support that can be found in all cultures and traditions. It has been described in our modern context as individual and corporate patience in which trained pastoral carers support people in their pain, loss and anxiety, and their triumphs, joys and victories. Spiritual care attends to a person’s spiritual or religious needs as he or she copes with illness, loss, grief or pain and can help him or her heal emotionally as well as physically, rebuild relationships and regain a sense of spiritual wellbeing.
For most of human history, in all major religions, an ultimate goal of spiritual practice was accomplishing a good death. When this goal was held in common by the whole society, spiritual care could focus on the interaction between a dying person and his or her caregivers.
A number of clergy have commented to me that spiritual care is not recognised by many aged care facility staff as important. They have frequently commented on services being interrupted by staff activity, or being asked to hold services or provide pastoral care in areas of the facility that are very close to the main entrance or actually in main thoroughfare areas. This is not respectful of the needs of the residents who choose to attend, or the need to peace and calm to receive spiritual care. In learning more about the importance of these concepts, it may support good holistic care for residents if you were to discuss with the clergy and pastoral care workers whether the circumstances being provided for them to support residents are appropriate.
There are lots of ‘trendy’ words in each work environment but one of the most important concepts which appears to be increasingly missing particularly in aged care nursing is that of critical thinking and reflective practice. Critical thinking is the core foundation of good nursing practice.
It is essential to evaluate what is occurring clinically for those in care and regularly reviewing what is being done for each individual resident along with what else needs to be done in order to provide the best care. The skills of critical thinking may not be instinctive for example for those nurses coming from a schooling system which promotes ‘rote’ learning and deters from challenging senior staff. To question another may be seen in some settings as disrespectful however in the field of clinical care, to challenge and question is essential. The attributes of those who critically think and reflect on nursing practice and care outcomes use evidence-based practice (EBP) guidelines including current EBP policies and procedures to form decisions.
Some of the skills of critical thinking are more important than others and certainly the ability to reflect while communicating with other members of the team is essential to safe and person centred care. The nurse who has developed critical thinking skills is able to interpret, understand and explain the meaning of information. This can be event based or data based eg; reading lab result forms. Investigating possible interventions based on the information at hand and analysing which will achieve a desired outcome is also part of reflecting and critically evaluating a clinical scenario. Assessing the value of information to determine it’s relevance, reliability and credibility in relation to a particular clinical presentation is also necessary.
There are potential barriers to optimising clinical outcomes by clinical staff when a pre-determined bias or fixed mind-set are applied to a set of data or resident clinical presentation. It’s only in the bringing together of information through evaluation, analysis, communicating, referencing EBP guidelines and a growth mind-set that care can be optimised.
Clinical documentation and clinical management relate to section 1.3.1 to 1.3.8 of the Health and Disability Services Standards and are referred to in section D5.4 of the ARRC. There are key reference documents which provide reference at residential care facility level which should be used in conjunction and addition to your organisation policies and procedures. These reference documents include:
Age Related Residential Care (ARRC) contract
NZS 8134:2008 Health and Disability Services Standards
Clinical best practice (EBP) guidelines – eg; Lippincott
The Code of Health & Disability Consumers Services Rights 1996
Clinical documentation errors of any type noted during audits will result in partial attainments at best. This is an indication there could be risk associated with gaps in service. In a previous article about medication management we noted that even a single signature missing off an administration signing sheet was enough for the auditor to assign a partial attainment finding.
Below are some of thecommon compliance gaps which relate to clinical documentation:
General compliance
gaps
Missed signatures off notations.
Not dated.
Not signed by the author with a full signature.
No designation written with signature.
Not legible.
Inconsistent structure of resident files.
Unclear or unsecured archiving of documents.
Privacy breaches due to clinical documents placed in a situation that allowed unauthorized viewing.
Initial assessments
including InterRai
Not completed within time-frames defined in ARRC.
Baseline recordings at time of admission not recorded.
Assessment outcomes not used as a basis of care planning to link assessment to goals and interventions.
Additional detailed assessments not reviewed in a timely manner eg; six monthly to coincide with InterRai reassessments.
Failure to re-assess for each period of admission eg; respite care.
Clinical risk
Assessment not describing risk.
Risk not reflected in care plan interventions.
Lack of risk reviews.
Level of risk noted in interRai assessments not included in care planning
Progress notes
Not recorded in on a shift by shift basis.
Lack evidence of regular registered nurse input.
Writing beyond the bottom line of the page.
Failure to put resident identifiers on each side of each page (this applies to other clinical documents as well).
Lack evidence of interventions being implemented.
Lack evidence of RN response to clinical symptoms reported by care staff.
Lack of evidence of rationale for PRN medication administration or the resulting effect.
Short Term
Care Plans
Not developed for changes in clinical status eg; increased pain; infection; wounds, change in medication (to allow evaluation of effectiveness).
24 hours plans not developed for residents displaying behaviours of concern (challenging behaviours).
Not evaluated regularly (I suggested at least once every 7 days) by a Registered Nurse.
Not recorded as resolved or transferred to Long Term Care Plan.
Not developed to implement instructions included in General Pracitioner consultation plans recorded in notes.
Long Term
Care Plan (LTCP)
Not reflective of all presenting potential and actual medical / clinical problems.
Not documented within 3 weeks of the date of admission (ARRC requirement).
Not changed at the time of health status / functional change.
Interventions not reflective of each medical diagnosis.
Interventions not changed within LTCP to reflect changes recorded in care plan evaluations.
Frequency of clinical assessment for each actual clinical presentation eg; pain.
Do not clearly indicate the level of function, assistance required for each component of care / support.
Do not clearly evidence input and instruction from Medical or Nurse practitioner / Physiotherapist, Diversional Therapist, Dietitian,Psychiatric services for the elderly etc.
Care Plan
Evaluations
Review of care plans not reflecting changes in residents health status as they occur.
Not reflective of how well the care plan goals/ objectives have been met since the previous evaluation.
Not completed within ARRC defined time-frames (at least six monthly).
Multi-Disciplinary
Input
Lack evidence of MDT input into care plan reviews and/or evaluations.
Lack evidence of resident, Next of Kin (NOK) / Family / Whanau / EPOA input into assessment and care planning.
Lack of evidence of timely referral in response to clinical presentation eg; unintentional weight loss not referred to Dietitian.
Failure to evidence implementing instructions ofMedical or Nurse Practitioner eg; B/P to be recorded daily for the next 7/7 may be noted in the medical consultation notes however not evidenced as having been done.
Lack evidence of notification to NOK / EPOA relating to resident adverse events, change in health status, medical consults etc.
Policy and
procedures
Not consistent with service delivery as noted in clinical documentation.
Internal audits are available through the online HCSL quality system utilised by our clients which allows tracking of compliance status and corrective actions as part of on-site quality and risk management. This means when the auditors arrive, there will be no surprises and you’ll know you’ve achieved excellence in care in conjunction with providing a compliant service.
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Workplace culture is a term bandied around a lot but what does it actually mean and how can it be measured? When I ask staff at facilities during training sessions what they see their point of difference is, they frequently reply saying ‘we’re friendly’, or ‘we care’ or ‘we provide a homely environment’. While these are all nice to have, they would actually be expected as a basic standard. They are not specific and not anything different to the care facility down the road.
Mary Barra, Chairwoman and CEO of General Motors (GM) states that at GM, they prefer to talk about behaviours rather than culture as behaviours can be changed very quickly and are apparent straight away. She talks about the need for rapid change with the inclusion of technology and advancements in artificial intelligence being used more frequently. While those are starting to be present in some aged residential care settings, what is true of both GM and aged care is rapid change and the need to adapt quickly. This isn’t going to happen by accident and needs clear direction, guidance, leadership and engagement of all those involved.
Mary Barra also refers to bringing products to market that bring people freedom, rather than talking about cars or transportation. She focuses on the outcome for their clients. What is the key outcome you’re wanting to provide for those in your environment and how is that defined in your values? How is it implemented by your staff and how do you measure success on those outcomes?
A managers oath as I’ve mentioned before is a good place to start in defining the governance or leadership direction of organisations. Values and key performance indicators (KPIs) or quality objectives / measures need to align to this.To ensure consistent progress regular review of those KPIs or quality measures needs to occur and acted on according to the outcomes. Policies and procedures to guide consistent best practice are an important part of ensuring clear direction for staff while setting parameters for performance. Information reduces confusion and promotes change. Practice creates confidence not only in the staff but also in the resident and those observing their care.
When balancing the clinical needs, requests and preferences of each resident in-conjunction with their right to choose, a number of factors need to be taken into consideration. We all recognise that theory and practice can change over time so when I asked Liz Beaglehole (Registered Dietitian) her professional view on this topic is, she offered the following:
The recommendation for older adults with diabetes in aged care facilities with stable diabetes is to provide an unrestrictive diet as much as possible. The notion of a ‘diabetic diet’ is outdated due to the increased risk of hypos and unwanted weight loss.
This is very individual however, a frail 80 year old woman with diabetes will likely have no diet restrictions however an obese 70 year old who may be otherwise stable would benefit from a more restrictive diet. Advice from a dietitian for individuals is recommended.
Overall, guidance from the resident about their wants is probably what determines the diet provided. This may be in accordance with recommendations or not.
Generally, the medications should be fitted to the usual eating pattern of the resident. In aged care facilities there are regular meals and generally balanced carbohydrates over the main meals (assuming good food intake) so usually this is fine. If someone has a reduced food intake, and is on insulin then a unrestrictive diet would be best.
For my menu planning I tend not to plan any special diabetic options on the cycle menus. I may include a low fat / low sugar dessert option if sites request, but generally my philosophy for aged care is not to restrict foods!
Liz is involved with a PEN (practiced based evidence in nutrition) review of the question ‘Do institutionalized, older adults (65 years of age or older) who closely follow a diet prescription have better control of their chronic disease (e.g. diabetes) than those who do not?‘ This is due by the end of March so further practice updates from this review may be available then. Liz noted that generally the evidence suggests there are no benefits with a prescriptive diet vs a more liberal one.
Workplace culture is a term bandied around a lot but what does it actually mean and how can it be measured? When I ask staff at facilities during training sessions what they see their point of difference is, they frequently reply saying ‘we’re friendly’, or ‘we care’ or ‘we provide a homely environment’. While these are all nice to have, they would actually be expected as a basic standard. They are not specific and not anything different to the care facility down the road.