The report was ordered by the Aged Care Minister Ken Wyatt after 10 residents died during an outbreak of influenza at the facility.
The Quality Agency audit found that the Nursing Home failed to meet 12 of the 44 expected outcomes from the Accreditation Standards.
The full report can be downloaded here :- http://www.aacqa.gov.au/publications/reports/stjohnsretirementvillagenursinghome4481-5.docx/@@download/file/stjohnsretirementvillagenursinghome4481-5.docx
Below is a summary of the audit findings for the Nursing Home section of the complex.
The information obtained through the audit indicates the Nursing Home did not meet expected outcomes.
Standard 1 – Management systems, staffing and organisational development
1.1 Continuous improvement
“The organisation does not have an effective system that demonstrates a proactive approach to continuous improvement across the Accreditation Standards.”
1.2 Regulatory compliance
“Management did not ensure staff reported allegations of elder abuse in a timely manner. Management did not ensure the respiratory outbreak case list was complete and reflected all deaths and hospitalisations. Management did not ensure all deaths and hospitalisations related to the influenza and respiratory outbreak of August 2017 and September 2017 were consistently notified to the Department of Health and Human Services in a timely manner within 24 hours. ”
1.3 Education and staff development
“Management and staff cannot demonstrate they had the appropriate knowledge and skills to identify, contain and manage the influenza and respiratory outbreak of August 2017 and September 2017. These skill and knowledge deficits impacted negatively on care recipients.”
1.4 Comments and complaints
“During the review audit, stakeholders raised concerns about staffing levels, skin care, pain management, continence and clinical care during the influenza and respiratory outbreak in August 2017 and September 2017. In addition, they raised concerns about infection control, cleaning and the level of communication during that time.”
1.6 Human resource management
“The organisation did not maintain a sufficient number of appropriately skilled and qualified staff during the influenza and respiratory outbreak of August 2017 and September 2017. There was not always a registered nurse on duty and the on call nurse did not always come in when requested after hours. ”
1.8 Information systems
“The organisation cannot demonstrate their information systems during the recent respiratory outbreak of August 2017 and September 2017 were effective. The policies, procedures and flowchart do not reflect current Australian Government and Victorian Government infection control guidelines.”
Standard 2 – Health and personal care
2.1 Continuous improvement
“Clinical monitoring and reporting mechanisms are ineffective and management cannot show key performance data that exceeded specified risk thresholds has been actioned, for example, falls, hydration status and number of medications prescribed.”
2.2 Regulatory compliance
“Management did not ensure qualified staff were always available and responsible for assessing and monitoring care recipients’ clinical care needs during the influenza and respiratory outbreak of August 2017 and September 2017. Staff did not always work according to legislative requirements or within their scope of practice in relation to verification of death, management of syringe drivers and controlled medication.”
2.4 Clinical care
“During the influenza and respiratory outbreak in August 2017 and September 2017 a number of care recipients did not receive appropriate clinical care. Three of ten care recipients who died with influenza or respiratory illness were not referred to a medical officer at the onset of their illness.”
2.8 Pain management
“Care recipients' pain was not effectively managed during the respiratory and influenza outbreak of August 2017 and September 2017. Staff said care recipients who were unwell during the outbreak died in pain because they could not provide timely repositioning and pain management resources were not always available. Pain relief medication was not always available for care recipients and pain charting was not always completed in order to evaluate the effectiveness of pain relief measures.”
2.11 Skin care
“During the influenza and respiratory outbreak of August 2017 and September 2017 a number of care recipients did not receive appropriate skin care. Seven of ten care recipients who died with respiratory illness had outdated information in assessments and care plans impacting on the delivery of care recipients’ skin care needs. Four of ten care recipients developed pressure areas during the outbreak with no action taken to initiate wound management plans or ensure treatments were ongoing. ”
Standard 3 – Care recipient lifestyle
3.2 Regulatory compliance
“Staff who received allegations of elder abuse did not always report the allegations in accordance with regulatory compliance obligations. Management said until September 2017 they were not aware they had to maintain a consolidated record of incidents where discretion not to report is used. The new consolidated record does not capture all incidents of care recipient to care recipient aggression.”
Standard 4 – Physical environment and safe systems
4.1 Continuous improvement
“Monitoring and reporting mechanisms to gather infection data, analyse data for trends and improvement opportunities are not effective. Infection data provided to the home’s benchmarking service has been inaccurate, resulting in performance monitoring and reporting that is incorrect. Systemic failures were identified in relation to the monitoring and actioning of the processes within the quality system in relation to Standard 4 Physical environment and safe systems.”
4.2 Regulatory compliance
“Management did not have systems to ensure management and staff followed all relevant guidelines in identifying, actioning and monitoring the influenza and respiratory outbreak in a timely manner from the onset of symptoms. Management was not aware of their responsibilities in relation to the reporting of the hospitalisation or deaths of care recipients with influenza or respiratory illness within 24 hours and did not comply with these requirements. ”
4.3 Education and staff development
“The home did not have an effective system to ensure management and staff had the required knowledge and skills to identify and contain infection during the influenza and respiratory outbreak of August 2017 and September 2017. Processes to ensure staff had appropriate knowledge and skills to perform their roles effectively during the outbreak did not occur until infection control education commenced on 22 August 2017.”
4.7 Infection control
“St John's Retirement Village Nursing Home did not implement a coordinated and timely infection control program that was effective in identifying and containing infection during the influenza and respiratory outbreak of August 2017 and September 2017. Management did not implement timely and effective infection control measures and did not provide co-ordination, direction and management during the outbreak to control the spread of infection.”
4.8 Catering, cleaning and laundry
“Infection control cleaning procedures were not consistently implemented during the influenza and respiratory outbreak of August 2017 and September 2017. Five cleaning staff and the environmental services manager were on unplanned leave at times during the outbreak and the leisure and lifestyle coordinator with no recent infection control training supervised environmental services staff. Cleaning shifts were not consistently replaced and when filled, the shifts were not always replaced with staff who had been trained in outbreak infection control.”
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