Influenza Deaths Board Accountability

Ten flu deaths at nursing home amid serious management failure

Influenza Deaths Board Accountability - The Board of Governors of St. Johns Village Wangaratta is showing no signs of accepting any responsibility for this influenza deaths tragedy.

 

•  In early 2016 the Director of Care position was made redundant.


• The Board introduced a flatter management structure


• The Australian Nursing and Midwifery Federation Victorian branch alleged that St John’s had breached its enterprise bargaining agreement by not employing a director of care – and consequently jeopardised its community reputation.


• Following a letter from the Board's lawyers claiming that they believed the statement was defamatory the ANMFV apologised for any inference that the Board may have failed in its governance obligations.


• Mr. Morris was appointed as acting Care Services Manager.


• On July 10 2017 Dr Brett Sutton, Deputy Chief Health Officer (Communicable Disease), Victoria issued a warning to all Victorian Health professionals and consumers that seasonal influenza rates are up, with the overall number of confirmed influenza cases in Victoria up 81 per cent compared to the same time in the calendar year 2016.


• The Board of Governors ultimately responsible for the operation of the facility includes a medical practitioner and also a member that claims a specialty in infection prevention and control.


• August 7 first signs of illness amongst residents.


• August 16 first death.


• Aged Care Minister Ken Wyatt instructs the quality agency to conduct a review audit of the St John’s Wangaratta aged care facility to assess their performance against the 44 accreditation standards, which includes infection control systems and processes.


• Aged Care Minister Ken Wyatt announced that the Wangaratta St. John’s Nursing Home failed multiple outcomes after an audit by the Australian Aged Care Quality Agency.


• One such area listed as a fail was 1.2 Regulatory Compliance.
  “The organisation’s management does not have an effective system to identify and promote compliance with all relevant legislation, regulatory requirements, professional standards and guidelines.”

Although the Board of Governors cannot be held responsible for influenza entering the nursing home they do carry a responsibility and an accountability for what happened once it did.  Is it a strength or a weakness of an organisation that simply sheets home the blame to individuals who were placed in positions but may subsequently be shown to be without the necessary experience to fulfil the role.

Whatever any shortcomings of the now resigned Mr. Morris may be, he was appointed to the position in an acting capacity by senior management.  Whatever any shortcomings of the now resigned CEO Mr. Phelps may be, he was appointed to the position by the Board.

The responsibility and accountability for this tragedy does not rest just with the sacrificial lambs Mr. Morris and Mr. Phelps alone.  If the buck doesn't stop with the Board then who does it stop with?


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St Johns Nursing Home Fails AACQA Audit

St Johns Nursing Home Fails AACQA Audit - Aged Care Minister Ken Wyatt announced that the Wangaratta  St. John's Nursing Home failed multiple outcomes after an audit by the Australian Aged Care Quality Agency.

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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Aged Care Influenza Reviews

Aged Care Influenza Reviews - The Hon Ken Wyatt AM, MP, Minister for Aged Care released the results of the AACQA  Influenza reviews for the St. John's aged care facility in Wangaratta Victoria and the Uniting AgeWell Strathdevon facility in Latrobe Tasmania.

The St. John's Wangaratta facility failed 13 of 44 outcomes with 12 deaths and the Uniting AgeWell Latrobe facility failed 5 of 44 outcomes with 6 deaths.

"The Australian Government today released detailed reviews of aged care homes in Victoria and Tasmania that suffered deadly influenza outbreaks this winter, which revealed poor facility management and low staff vaccination rates.
Federal Aged Care Minister Ken Wyatt ordered the review by the Australian Aged Care Quality Agency of the St Johns facilities in Wangaratta and the Strathdevon facility in Latrobe during the influenza outbreak in August and September.
“These review audits reveal management errors, especially in infection control at the two sites,” Minister Wyatt said.
“The flu season affected aged care residents and staff and the homes’ infection control and contingency plans were overwhelmed but it was unacceptable.
“Staff vaccination rates in both homes were low, with only around one-third vaccinated ahead of the outbreaks, and dozens of staff were subsequently struck down with the flu.”
In response, Health Minister Greg Hunt has moved to make it mandatory for aged care facilities to implement flu vaccination programs for staff, with Chief Medical Officer Dr Brendan Murphy currently examining all options to increase vaccination rates.
These reviews have found that at both sites, the homes’ management did not provide enough additional support and the professional guidance that was required to cope with the outbreak.
Minister Wyatt said the Quality Agency had now greatly increased its focus on the issue of infection control at all aged care facilities.
“The Agency is reviewing infection control practices, including a mandatory survey of all facilities’ outbreak management and staff vaccination rates, which is due for completion next week,” said Minister Wyatt.
“Results will be collated, then the Agency will focus on and engage with all homes which have registered low vaccination rates or difficulties managing the 2017 flu season.”
The Quality Agency is also running staff seminars in every aged care jurisdiction at present, to strengthen quality monitoring around infection control and increase staff and resident vaccinations.
Targeted aged care communication and education materials will be developed for the 2018 influenza season to further promote staff influenza vaccination.
All aged care providers have also been asked to review their infection control practices, to ensure that they are well equipped to manage and respond to an outbreak.
“Providing safe, quality aged care for our senior Australians is non-negotiable,” Minister Wyatt said.
“I am closely monitoring developments, and ensuring all Government-funded aged care facilities are prepared for infectious outbreaks, especially influenza, is a top priority.”
The reports are available at:
St John’s Retirement Village Hostel
http://www.aacqa.gov.au/publications/reports#b_start=0&c8=3293
St John’s Retirement Village Nursing Home
http://www.aacqa.gov.au/publications/reports#b_start=0&c8=4481
Uniting AgeWell Strathdevon
http://www.aacqa.gov.au/publications/reports#b_start=0&c5=strathdevon&c8=8405

Aged Care Influenza Reviews

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St Johns Hostel Fails AACQA Audit

St Johns Hostel Fails AACQA Audit - Wangaratta Aged Care facility St. John's Village has failed multiple outcomes following an audit by the Australian Aged Care Quality Agency.

The report was ordered  by the Aged Care Minister Ken Wyatt after 10 residents died from influenza.

Following a review audit the Quality Agency decided that the Hostel section of the complex failed to meet 12 of the 44 expected outcomes of the Accreditation Standards.

The full report is available for download here :- http://www.aacqa.gov.au/publications/reports/stjohnsretirementvillagehostel3293-5.docx/@@download/file/stjohnsretirementvillagehostel3293-5.docx

The following is a summary of the audit findings for the Hostel section of the complex.

The information obtained through the audit indicates the Hostel does not meet the following 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. ”

1.2Regulatory 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. ”

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 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. ”

1.8 Information systems

“The respiratory outbreak case list used to provide accurate information to the Department of Health and Human Services was incomplete and did not reflect all care recipients’ hospitalisations and deaths.”

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.”

2.4 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. Not all care recipients who received treatment for respiratory illness were referred to a medical officer at the onset of their illness.”

Standard 3 – Care recipient lifestyle

3.2 Regulatory compliance

“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.”

Standard 4 – Physical environment and safe systems

4.1 Continuous improvement

“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 were not aware of their responsibilities in relation to the reporting of the hospitalisation 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.”

4.7 Infection control

“Organisational policies and procedures to direct staff response during a respiratory outbreak are not in line with current Australian Government and Victorian Government infection control guidelines that define an outbreak as three or more people (care recipients or staff) showing symptoms within the same three day period. ”

4.8 Catering, cleaning and laundry

“Management cannot demonstrate that hospitality services are provided in a way that enhances care recipients’ quality of life and the staff working environment. Infection control cleaning procedures were not consistently implemented during the influenza and respiratory outbreak of August 2017 and September 2017.”

St Johns Hostel Fails AACQA Audit.




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ACQA Reports St. John's Aged Care Failures

ACQA Reports St. John's Aged Care Failures - Melbourne Age in an article by Michael Bachelard and Ebony Bowden reports -

Ten flu deaths at nursing home amid serious management failure

"A fatal flu outbreak at a Wangaratta nursing home, where 10 residents died of influenza and two others from respiratory illness, was worsened by serious management failures, a scathing government audit has found.

In response, the St John's Village nursing home accepted the resignation of its own former acting care services manager and referred him to his professional body for potential sanction.

A federal government audit of the St John's Village home, which was ordered after the catastrophic outbreak, has found it took days after infections began in August for management to report the outbreak."

Read the detailed article here:- http://www.theage.com.au/victoria/ten-flu-deaths-at-nursing-home-amid-serious-management-failure-20171113-gzk29h.html

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The Real Cost of Village Living

The Real Cost of Retirement Village Living

A recent report into Retirement Village living drew the following conclusion:-

Conclusion
"Seniors make the choice to live in retirement villages based on a range of personal and financial factors.
The amenity and social aspects of retirement village living provide much of the benefit of this choice.
Commensurate medium density apartment buildings provide accommodation but they do not provide the
benefits found in retirement villages."

http://www.retirementliving.org.au/wp-content/uploads/2013/12/COMBINED-REPORT-6-Oct-2017.pdf

The following table examines what is a measured cost of this part of the statement -

"The amenity and social aspects of retirement village living provide much of the benefit of this choice."

The table examines a retirement village where the in-going cost is $850,000.00, a Deferred Management Fee of 35% of this amount, 0% of any Capital Gain going to the resident, maintenance fees, a refurbishment cost, loss of earnings on the refundable amount of $552,500.00 ($850,000.00 minus $850,000.00 x 35%). The refundable amount is held by the operator until the resident leaves the village.

The tangible value of the residential accommodation was calculated at a return of 4% to a landlord. (see included table on rental returns)

A tangible rental value of $653.80 per week.

The cost of the intangible value  "The amenity and social aspects of retirement village living" a whopping $1014.40 per week.

A total capital value cost to a resident of $1668.20 per week over 7 years.

Retirees could simply rent a commensurate property within the general community for $653.80 per week and retain their capital amount of $850,000.00.

The Real Cost of Retirement Village Living.

 

Uniform Retirement Village Laws

Uniform Retirement Village Laws -

Herald Sun reports :-

Federal Government tells states to create uniform retirement village laws to protect seniors

"STATES have been put on notice to change their laws to better protect their retirement village residents and their families or face federal intervention.

Federal Consumer Affairs Minister Michael McCormack has given state counterparts until the first half of next year to create plans to overhaul legislation covering villages, with evidence lax and un-enforced laws were being manipulated by unscrupulous owners and operators."

Take this link to see the full comprehensive story:- Federal Government tells states to create uniform laws to protect seniors


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