Summary

RESIDENTIAL SERVICES QUALITY REVIEW

RETIREMENT CONCEPTS

SUMMERLAND SENIORS VILLAGE

NOVEMBER, 2012

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SUMMERLAND SENIORS VILLAGE SITE VISIT INFORMATION

Address

12803 Atkinson Road Summerland, B.C. V0H 1Z4 Tel: 250-404-4400

Date: November 2 & 5, 2012

Owner Information

Retirement Concepts Azim Jamal, President & CEO Tony Baena, Vice President of Operations 1160-1090 West Georgia Street Vancouver, BC V6E 3V7 www.retirementconcepts.com

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.

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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.

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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.

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

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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,

2012. 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

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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

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.

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.

Orientation Checklists Inconsistent completion of orientation with new employees as evidenced by recent nurse hires in last four months (July – Oct).

7. Ensure all staff complete orientation checklists and follow up action plans.

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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).

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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.

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THEME FINDINGS RECOMMENDATIONS

CLINICAL

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 2.0.

20. Follow mandated assessment guidelines for RAI 2.0.

21. 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.

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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.

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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.

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THEME FINDINGS RECOMMENDATIONS

Violence Prevention Program

No evidence of violence prevention policy. Evidence found of examples of workplace violence.

41. Violence prevention program is implemented as soon as possible to all staff.

Infection Control Lack of processes in place to guide staff in cleaning and changing personal items (basins, urinals).

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.

Appendix A: Residential Care - Priority Areas for Summerland Seniors Village, Summerland

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THEME COMPLETED BY OUTCOMES

LEADERSHIP FOR THE ESTABLISHMENT OF A SOLID FOUNDATION FOR CARE TEAM

January 7, 2013

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 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

Appendix A: Residential Care - Priority Areas for Summerland Seniors Village, Summerland

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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, 2012