“HCSL has been incredibly easy to navigate since we went live on the system on the 1st of October. Our team have people with varying levels of technology literacy and the ease of this system has meant that staff are more confident to use technology and see how it can help to improve time management by not having to double or triple up on written documentation.”
Manager
Alexander House Rest Home
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:
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 the common 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.
If you have any comments to make about this article, please contact us here.
Upon reading one policy everything fell neatly into place. I found her documentation to be outstanding. It is very reassuring to know that every policy and procedure is the most up to date and designed to meet audit requirements. All her forms are easily accessible and very user friendly. We can instantly benchmark against others. At the click of a button we can analyse falls, infections and adverse events. Creating graphs and other information for Board reports takes minutes rather than hours.
Having come from a background of many years in QA, HSE and Electronic Document Management in the Oil and Gas Industry, when I entered the aged care sector, it was a huge “eye opener”. After sitting through several handovers and meetings and listening to discussions on medications etc I felt as if I was listening to a foreign language. Oh my goodness I thought and then Gillian’s documentation arrived together with a visit from her shortly after.
Gillian’s enthusiasm and commitment for both the aged care sector and her documentation is contagious. I feel I can now discuss, with the knowledge I have acquired in a few short months, aspects of aged care I never knew existed. Gillian is only a phone call or email away and all queries are always answered promptly, no matter how minor.
Thank you very much Gillian.
Lois Lash – Quality Assurance
Tainui Village – October 2017
HCSL is still the only New Zealand provider that, along with our software offer fully customised (Site by Site) up to date. New Zealand compliant policies & procedures, so you don’t have to update, edit or create them yourselves.
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.
‘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
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.