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RESIDENTIAL SERVICES QUALITY REVIEW Interior Health
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SUMMERLAND SENIORS VILLAGE SITE VISIT INFORMATION,12803 Atkinson Road. Summerland B C,Address Date November 2 5 2012,Tel 250 404 4400. Retirement Concepts,Azim Jamal President CEO, Tony Baena Vice President of Operations Author of Summary. Karen Bloemink Regional Director,Owner Information. 1160 1090 West Georgia Street Residential Services. Vancouver BC Interior Health Authority,www retirementconcepts com.
75 Interior Health funded units, Residential Care Component of Campus 5 private units. Total of 80 licensed units,Residential Services Quality Review. The Interior Health Authority Residential Services program has a well established process for monitoring the quality of services being. provided in a residential care setting This process has been in place since 2006 and is used for the following reasons. 1 To routinely monitor the quality of services being provided against Long Term Care Standards identified by Accreditation Canada. inclusive of Required Organizational Practices defined as essential practices that organizations must have in place to enhance. resident safety and minimize risk Residential Care Regulations overseen by the Licensing Branch authorized within the Community. Care and Assisted Living Act and Ministry of Health requirements including those outlined in the Home and Community Care Policy. Manual and requirements and obligations as identified in the Interior Health Authority Operating Agreement with private providers. 2 To identify areas for improvement or areas of exemplary work that can be shared throughout the program. 3 To provide comprehensive formalized review of a facility wherein unresolved complaints or concerns represent significant risk to. residents in care, The Residential Services Quality Review RSQR is conducted routinely in all facilities providing residential care If concerns are identified this. review may be conducted more frequently based on the nature of the findings to ensure follow up action is occurring The RSQR is. conducted by an interdisciplinary team of experts who support the site through a self evaluation process which is followed by an on site. review During the self evaluation and onsite review the following sources of information are utilized. InterRAI MDS 2 0 data for site,Staffing schedules daily staffing flow sheets. Licensing reports,Critical Incident reports,Complaints concerns.
Communication records resident care records, Conversations with staff residents and families resident family councils. Administration management clinical support to site including recreational activity calendars resident participation records. evidence of education and participation evidence of policy and procedure to support care evidence of roles responsibilities and. expectations of staff,Background, The Summerland Seniors Village in Summerland BC has had experience with the Interior Health Authority s RSQR process over the last few. years and had a full review conducted in September 2011 At that time there were a series of recommendations that were placed into an. action plan and served as the quality improvement plan for the site The Retirement Concepts management team was responsible for. carrying out the improvements necessary with progress reports required by Interior Health. Licensing conducted a formal inspection of this site in May 2012 and some minor concerns were identified for correction. In August 2012 a serious incident occurred resulting in the death of a resident which triggered an in depth investigation As this. investigation took place several other care related concerns were raised with the Interior Health Authority and follow up on these. complaints occurred individually Due to the serious nature of these concerns Interior Health Authority Residential Services requested an. additional inspection be conducted by Licensing which occurred on Oct 31 2012 There were 19 serious infractions found at this time. During the follow up investigation on November 14 2012 further infractions were found The reports of these inspections are posted on the. Interior Health public website and can be located at http www interiorhealth ca YourEnvironment InspectionReports Pages default aspx. Due to the serious nature of the findings Interior Health initiated a RSQR which was conducted on November 2 and November 5 2012. Objectives, The objectives of the Retirement Concepts Summerland Seniors Village RSQR Nov 2012 process are to. 1 Ensure residents at Summerland Seniors Village residential care receive a safe and satisfactory quality of care. 2 Monitor the ongoing Retirement Concepts action plan to address current and ongoing quality of care issues staffing issues and. requirements under the Continuing Care and Assisted Living Act. 3 Implement a proactive plan to identify outstanding quality of care issues that arise heighten monitoring and determine short. medium and long term monitoring processes to ensure that quality of care improvements are maintained over time. The RSQR is designed to closely review Summerland Seniors Village organizational care practices against regulations and. standards in order to identify strengths and areas for improvement. The RSQR can be organized according to the following themes. Leadership for the establishment of a solid foundation for the care delivery team. Communication,Quality improvement and risk management. Corporate organizational support, As per the Interior Health Authority Residential Service Quality Review process an interdisciplinary team consisting of administrative nursing.
and allied health care providers led by the Quality Coordinator for the South Okanagan was identified During the course of the review the. team spent time working closely with the staff and management of Summerland Seniors Village reviewing the quality of care and service. delivery Following the completion of the review a report was prepared and shared with the management of the site on November 22. 2012 In response to this report Summerland Seniors Village management developed an action plan to address the areas of concern. A number of recommendations were identified for quality of care improvements through the RSQR process with Summerland Seniors Village. Staffing challenges have emerged as having a contributing role to many of the quality of care issues identified These challenges include. Staff on care team working within limited scope,Limited skill mix on care team. Insufficient tools in place to support staff routines job expectations communication tools reporting relationships. High incidence of last minute shift cancelation,Low success rate in filling last minute shifts. Lack of systems in place for shift staffing replacements. Insufficient processes in place for effective management of staffing needs. The following table summarizes the findings related to each of the themes above with related recommendations. THEME FINDINGS RECOMMENDATIONS,THEME FINDINGS RECOMMENDATIONS. Leadership for the establishment of a solid foundation for the care team. Staffing hours not available to reviewers due to,changes in the staffing matrix due to temporary. bed closures,1 Required staffing levels at 3 15 combined care.
hours resident day 2 8 direct care 0 35 allied care. No evidence of Physiotherapy Occupational,Appropriate and. Therapy or Social Worker resources in the site to,adequate staffing. provide services to residents, levels 2 Inclusion of required allied care staffing 0 35 care. hours resident day, Limited evidence found to support the provision of. meaningful activities to residents as part of their. daily care,3 Support LPN to work to full scope,Residential Care Aide RCA staff do not chart and.
reported that they used to chart but stopped and,4 Support RCA to work to full scope. they were not sure why they stopped, Staff Development 5 Ensure all staff are trained on safety procedures fire. Inconsistent evidence of fire drills, 6 Ensure care team has knowledge and skills to make. In chart audits no evidence of tools to ensure that. decisions related to referrals to interdisciplinary team. changes in resident condition are being addressed,Inconsistent completion of orientation with new. 7 Ensure all staff complete orientation checklists and. Orientation Checklists employees as evidenced by recent nurse hires in. follow up action plans,last four months July Oct,THEME FINDINGS RECOMMENDATIONS.
No evidence of education calendar 8 Ensure education is conducted as identified by. Education Accreditation Canada along with timely ongoing. Staff verbalized need for baseline education clinical practice support. No performance reviews completed on care staff,within the last year. Performance Reviews 9 Performance reviews completed for all staff. Some limited evidence of small numbers of,reviews in dietary and housekeeping departments. COMMUNICATION,Incomplete use of shift change tools currently in. 10 Ensure effective method for staff to access important. resident information at shift change 24 report,Chart audits revealed evidence of inaccurate. Accessing Sharing 11 Review clinical documentation for accuracy and. information and use of abbreviations,Resident Information abbreviations.
A lack of resident specific recreational activities. 12 Develop methods of sharing resident activities among. identified observed on Activity of Daily Living,the care team ADL sheets. ADLs sheets,THEME FINDINGS RECOMMENDATIONS, 13 Resident care delivery areas have a process in place for. communicating which staff are working each day, Communication No observable method of communicating staff. between staff assignments with residents families and other. 14 Ensure organization has an effective mechanism in. members staff in the resident care delivery areas, place for communicating important information to all. Patient Care Quality Office information not, Patient Care Quality 15 Include Patient Care Quality Office information in.
available on admission or posted within the, Office admission packages and place throughout building. THEME FINDINGS RECOMMENDATIONS, 16 Completion of resident focused assessment and care. planning in a timely manner with input from team, Current staffing levels not allowing time to conduct. required care planning rounds as reported by, 17 Ensure there is documented care conference date. participants content and outcomes identified,Current tools not supporting comprehensive.
18 Identification of resident specific goals of care. assessment i e admission checklist,identified in care plan. Evidence of limited team involvement in care, Assessment Care 19 Clinicians trained in RAI and validated annually to. conferencing,Planning ensure competent assessment with RAI 2 0. 20 Follow mandated assessment guidelines for RAI 2 0. Care plans that were available were not specific to. individual resident and were out of date, 21 Evidence of falls assessment for those residents at high. Staff not trained to RAI 2 0 standards as evidenced. by low compliance with annual AIS testing for, 22 Implement a process to identify and care plan for.
inter rater reliability, those residents identified as at risk for aggressive. behaviours,THEME FINDINGS RECOMMENDATIONS, 23 Ensure most effective products are used in a timely. Provider is in the process of changing supplier for. manner to prevent skin breakdown,wound care supplies. 24 Establish procedures for monitoring skin integrity as. Policy refers to an online wound care course,part of resident assessment and care planning. however staff are not aware of it,Wound Care, 25 Ongoing education for staff in prevention of skin.
Rate of acquired pressure ulcers increasing,Wound assessments and consultation with wound. care specialists are not apparent in the resident, 26 All incontinent residents are identified and have a. toileting plan in place, 27 Formal med reconciliation training for clinicians. Majority of medication reconciliation is being done. by pharmacy,28 Evidence that all medication carts are locked. Chart audit indicated low understanding of, 29 Real time education and investigation following all.
medication reconciliation process by care staff,Medication medication incidents. Administration, Limited evidence of investigation and follow up on. 30 Ensure there is a mechanism for staff to assess. review of medication incidents,effectiveness of PRN medication use and document. Chart audit indicated no follow up on effectiveness. of PRN medication use,31 Establish process for regular narcotic audits. 32 Assessment for pain using evidence informed tools and. Could not find evidence of pain assessment on, Pain Management delivery of education for staff related to pain.
admission only used as needed,assessment and management. THEME FINDINGS RECOMMENDATIONS,Policy in place but not followed. 33 Follow established policy for restraint use,Unable to find guidelines or procedure to assist. staff in decision making related to restraint use 34 Implement tools to assist staff in assessment for. Restraint Use,residents when restraint use is considered. No evidence in resident charts that family or, resident have requested the use of devices such as 35 Assess all current residents on restraints for most.
a seat belt or side rails appropriate plan of care. 36 Ensure transfer assessments are done for all residents. Assessment forms not being utilized for resident, 37 Evidence of detailed intervention plan and use of Scott. Falls Risk Assessment on admission for all residents as. Falls Prevention Scott falls risk assessment is only done on. part of RAI assessment as well as each time a fall has. been experienced,Evidence of falls without follow up. 38 Evidence of education on falls prevention for all staff. QUALITY IMPROVEMENT RISK MANAGEMENT, 39 Ensure all reportable incidents as identified in the. Audit of incident reports revealed that many were, Residential Care Regulation are reported and followed. not followed up according to policy,up according to SSV policy.
Reportable Incidents,Not all incidents reviewed were disclosed to the. 40 Evidence of disclosure to clients and families regarding. THEME FINDINGS RECOMMENDATIONS,No evidence of violence prevention policy. Violence Prevention 41 Violence prevention program is implemented as soon. Program as possible to all staff,Evidence found of examples of workplace violence. 42 Processes in place for cleaning and disinfection of. resident care equipment including assignment of, Lack of processes in place to guide staff in cleaning responsibility and monitoring. Infection Control,and changing personal items basins urinals.
43 Ensure all outside medical reprocessing equipment. meets required standard,CORPORATE ORGANIZATIONAL SUPPORT. 44 Evidence of regional clinical policies and procedures. for the following,o Pain Management, Clinical Policies and Evidence of Least Restraint policy but not utilized o Wound Care. Procedures by staff at site o Least Restraint Use,o Falls Prevention. o Medication Reconciliation,o interRAI MDS 2 0,Conclusion. Interior Health Authority is committed to ensuring that the quality of care and services delivered to residents of all residential care sites. meets and or exceeds the identified standards As outlined in this summary of the Summerland Seniors Village Residential Care Quality. Review there are numerous concerns for quality of care identified in the findings and Interior Health Residential Services is working very. closely with Retirement Concepts and IHA Licensing in order to ensure the safety of those in care in this facility. Appendix A Residential Care Priority Areas for Summerland Seniors Village Summerland. THEME COMPLETED BY OUTCOMES, Stabilize staffing in site for effective clinical leadership and care provision staffed to required Total Resident Care Hours of 3 15.
Clinical leadership for care team that reflects professional clinical oversight Director of Care on site will be deployed as clinical. RN to work with care team to attend to,o clinical assessments. o care planning,o mentoring the team,LEADERSHIP FOR THE. o liaising with integrated team families,ESTABLISHMENT OF A. January 7 2013 o lead care conferencing,SOLID FOUNDATION FOR. Interdisciplinary Care Team with required competencies to be firmly in place. Interdisciplinary Care Team conferences including resident family involvement. Clearly defined roles and responsibilities for members of care team including. o reporting relationships,o establishment of routines.
Evidence of clear communication processes with,COMMUNICATION o Staff. January 7 2013,o Residents,o Families Caregivers, Documented evidence and identification of resident focused. CLINICAL o assessment,March 7 2013,o care plan,o outcomes for care. 1 P a ge Ja nua ry 2 2 2 0 1 3, Appendix A Residential Care Priority Areas for Summerland Seniors Village Summerland. THEME COMPLETED BY OUTCOMES, Development of clinical assessment outcomes and procedures for.
o Pain management,o Wound care,o Least restraint,o Falls prevention. o Medication Reconciliation,o interRAI MDS 2 0, Incident Reports consistent reporting and follow up. QUALITY IMPROVEMENT, March 7 2013 Quality Outcomes consistent reporting and follow up. RISK MANAGEMENT, Internal Quality Indicator Reports consistent review and follow up. Planning and development to support all aspects of operations. Quality Framework,ORGANIZATIONAL April 7 2013, SUPPORT Regional policies and procedures founded on evidence based practice current standards and legislation i e consent.
Support for local operations i e mentorship and education. REFERENCED DOCUMENTS, IH Recommendations from Residential Care Quality Review conducted Nov 2 5 2012. Residential Care Facility Report Licensing Oct 31 Nov 14 2012. Summerland Senior s Village Facility Plan Nov 30 2012.


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