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:

 
CriteriaGaps 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.

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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

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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 report “for 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.

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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

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