RESIDENTIAL SERVICES QUALITY REVIEW RETIREMENT CONCEPTS SUMMERLAND SENIORS VILLAGE NOVEMBER, 2012

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1 Summary RESIDENTIAL SERVICES QUALITY REVIEW RETIREMENT CONCEPTS SUMMERLAND SENIORS VILLAGE NOVEMBER, 2012

2 Address Owner Information SUMMERLAND SENIORS VILLAGE Atkinson Road Summerland, B.C. V0H 1Z4 Tel: Retirement Concepts Azim Jamal, President & CEO Tony Baena, Vice President of Operations West Georgia Street Vancouver, BC V6E 3V7 SITE VISIT INFORMATION Date: November 2 & 5, 2012 Author of Summary: Karen Bloemink, Regional Director Residential Services Interior Health Authority Residential Care Component of Campus 75 Interior Health funded units 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

3 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 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. 3

4 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, 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: Due to the serious nature of the findings, Interior Health initiated a RSQR which was conducted on November 2 and November 5, 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. Themes 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 4

5 Communication Clinical Quality improvement and risk management Corporate/organizational support Process 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, In response to this report Summerland Seniors Village management developed an action plan to address the areas of concern. Findings 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 5

6 THEME FINDINGS RECOMMENDATIONS Leadership for the establishment of a solid foundation for the care team Appropriate and adequate staffing levels Staffing hours not available to reviewers due to changes in the staffing matrix due to temporary bed closures. No evidence of Physiotherapy/Occupational Therapy or Social Worker resources in the site to provide services to residents. Limited evidence found to support the provision of meaningful activities to residents as part of their daily care. 1. Required staffing levels at 3.15 combined care hours/resident/day (2.8 direct care & 0.35 allied care). 2. Inclusion of required allied care staffing (0.35 care hours/resident/day). Staff Development Orientation Checklists Residential Care Aide (RCA) staff do not chart and reported that they used to chart, but stopped and they were not sure why they stopped. Inconsistent evidence of fire drills. In chart audits, no evidence of tools to ensure that changes in resident condition are being addressed. Inconsistent completion of orientation with new employees as evidenced by recent nurse hires in last four months (July Oct). 3. Support LPN to work to full scope. 4. Support RCA to work to full scope. 5. Ensure all staff are trained on safety procedures (fire). 6. Ensure care team has knowledge and skills to make decisions related to referrals to interdisciplinary team members. 7. Ensure all staff complete orientation checklists and follow up action plans. 6

7 THEME FINDINGS RECOMMENDATIONS Education No evidence of education calendar. Staff verbalized need for baseline education. 8. Ensure education is conducted (as identified by Accreditation Canada) along with timely ongoing clinical practice support. Performance Reviews No performance reviews completed on care staff within the last year. Some limited evidence of small numbers of reviews in dietary and housekeeping departments. 9. Performance reviews completed for all staff. COMMUNICATION Accessing/Sharing Resident Information Incomplete use of shift change tools currently in use. Chart audits revealed evidence of inaccurate information and use of abbreviations. A lack of resident specific recreational activities identified observed on Activity of Daily Living (ADLs) sheets. 10. Ensure effective method for staff to access important resident information at shift change (24 report). 11. Review clinical documentation for accuracy and abbreviations. 12. Develop methods of sharing resident activities among the care team (ADL sheets). 7

8 THEME FINDINGS RECOMMENDATIONS Communication between staff members No observable method of communicating staff assignments with residents/families and other staff in the resident care delivery areas. 13. Resident care delivery areas have a process in place for communicating which staff are working each day. 14. Ensure organization has an effective mechanism in place for communicating important information to all staff. Patient Care Quality Office Patient Care Quality Office information not available on admission or posted within the facility. 15. Include Patient Care Quality Office information in admission packages and place throughout building. 8

9 CLINICAL THEME FINDINGS RECOMMENDATIONS Assessment/Care Planning Current staffing levels not allowing time to conduct required care planning rounds, as reported by staff. Current tools not supporting comprehensive assessment (i.e., admission checklist). Evidence of limited team involvement in care conferencing. Care plans that were available were not specific to individual resident and were out of date. Staff not trained to RAI 2.0 standards as evidenced by low compliance with annual AIS testing for inter-rater reliability. 16. Completion of resident focused assessment and care planning in a timely manner with input from team. 17. Ensure there is documented care conference date, participants, content, and outcomes identified. 18. Identification of resident specific goals of care identified in care plan. 19. Clinicians trained in RAI and validated annually to ensure competent assessment with RAI Follow mandated assessment guidelines for RAI Evidence of falls assessment for those residents at high risk. 22. Implement a process to identify and care plan for those residents identified as at risk for aggressive behaviours. 9

10 THEME FINDINGS RECOMMENDATIONS Wound Care Provider is in the process of changing supplier for wound care supplies. Policy refers to an online wound care course however, staff are not aware of it. Rate of acquired pressure ulcers increasing. Wound assessments and consultation with wound care specialists are not apparent in the resident charts. 23. Ensure most effective products are used in a timely manner to prevent skin breakdown. 24. Establish procedures for monitoring skin integrity as part of resident assessment and care planning. 25. Ongoing education for staff in prevention of skin breakdown. 26. All incontinent residents are identified and have a toileting plan in place. Medication Administration Majority of medication reconciliation is being done by pharmacy. Chart audit indicated low understanding of medication reconciliation process by care staff. Limited evidence of investigation and follow up on review of medication incidents. Chart audit indicated no follow up on effectiveness of PRN medication use. 27. Formal med reconciliation training for clinicians. 28. Evidence that all medication carts are locked. 29. Real time education and investigation following all medication incidents. 30. Ensure there is a mechanism for staff to assess effectiveness of PRN medication use and document same. 31. Establish process for regular narcotic audits. Pain Management Could not find evidence of pain assessment on admission only used as needed. 32. Assessment for pain using evidence informed tools and delivery of education for staff related to pain assessment and management. 10

11 THEME FINDINGS RECOMMENDATIONS Restraint Use Policy in place but not followed. Unable to find guidelines or procedure to assist staff in decision making related to restraint use. No evidence in resident charts that family or resident have requested the use of devices such as a seat belt or side rails. 33. Follow established policy for restraint use. 34. Implement tools to assist staff in assessment for residents when restraint use is considered. 35. Assess all current residents on restraints for most appropriate plan of care. Falls Prevention Assessment forms not being utilized for resident transfers. Scott falls risk assessment is only done on admission. Evidence of falls without follow up. 36. Ensure transfer assessments are done for all residents. 37. Evidence of detailed intervention plan and use of Scott Falls Risk Assessment on admission for all residents as part of RAI assessment, as well as each time a fall has been experienced. 38. Evidence of education on falls prevention for all staff. QUALITY IMPROVEMENT / RISK MANAGEMENT Reportable Incidents Audit of incident reports revealed that many were not followed up according to policy. Not all incidents reviewed were disclosed to the family. 39. Ensure all reportable incidents, as identified in the Residential Care Regulation, are reported and followed up according to SSV policy. 40. Evidence of disclosure to clients and families regarding incidents. 11

12 THEME FINDINGS RECOMMENDATIONS Violence Prevention Program Infection Control No evidence of violence prevention policy. Evidence found of examples of workplace violence. Lack of processes in place to guide staff in cleaning and changing personal items (basins, urinals). 41. Violence prevention program is implemented as soon as possible to all staff. 42. Processes in place for cleaning and disinfection of resident care equipment, including assignment of responsibility and monitoring. 43. Ensure all outside medical reprocessing equipment meets required standard. CORPORATE / ORGANIZATIONAL SUPPORT Clinical Policies and Procedures Evidence of Least Restraint policy but not utilized by staff at site. 44. Evidence of regional clinical policies and procedures for the following: o Pain Management o Wound Care 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. 12

13 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 LEADERSHIP FOR THE ESTABLISHMENT OF A SOLID FOUNDATION FOR CARE TEAM January 7, 2013 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 o liaising with integrated team/families o lead care conferencing 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 COMMUNICATION January 7, 2013 Evidence of clear communication processes with: o Staff o Residents o Families/Caregivers CLINICAL March 7, 2013 Documented evidence and identification of resident-focused: o assessment o care plan o outcomes for care 1 P a g e J a n u a r y 2 2,

14 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 QUALITY IMPROVEMENT & RISK MANAGEMENT March 7, 2013 Incident Reports consistent reporting and follow up Quality Outcomes consistent reporting and follow up Internal Quality Indicator Reports consistent review and follow up CORPORATE / ORGANIZATIONAL SUPPORT April 7, 2013 Planning and development to support all aspects of operations Quality Framework 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, P a g e J a n u a r y 2 2,