Accreditation Bulletin #3 – Resident Safety

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BULLETIN #3 – RESIDENT SAFETY

Resident safety is one of the Accreditation Required Organizational Practices (ROP’s) that must be met to successfully complete Accreditation which will occur October 17-20, 2022. Menno Place has a Resident Safety Plan to ensure our delivery of care and services are provided safely to the residents and for the team members. Here is the summary information of our Menno Place Resident Safety Plan. The full plan can be found on SharePoint.

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ROP: Resident Safety Plan

Surveyor Question:  Does Menno Place have a developed and implemented Resident Safety Plan?
Answer:  Yes, Menno Place has a Resident Safety Plan that assesses and addresses resident safety. 

Evidence:  How do we do this?
The Resident Safety Plan supports Menno Place’s mission and vision by providing the mechanisms to improve resident safety and reduce identified risks. This is accomplished through the collection and analysis of data from various direct care and support functions of the care home within Menno Place.

A number of indicators are reported to Fraser Health including:

  • % of residents with worsened behaviours
  • % of residents with urinary tract infections
  • % of residents with stage 2-4 pressure ulcers
  • % of residents with pain
  • % of residents with unscheduled transfers to emergency
  • % of residents with restraints
  • % of residents that have fallen
  • % of residents with antipsychotics without a diagnosis
  • % of residents prescribed more than 9 medications

Internal monitoring of resident safety measures and practices designed to address and evaluate safety matters include, but are not limited to:

  • Ongoing education, training, and communication, including hand hygiene audits
  • Tending of incidents and near misses, and initiating improvement projects
  • Medication reconciliation at move-in and during transfers
  • Incident Reports
  • Resident/Family concerns/complaints
  • Employer incident investigation report
  • Pharmacy input and interventions
  • Licensing agency complaints/investigation
  • Resident healthcare record reviews
  • Workplace safety audit
  • Heat Preparedness Plan

Proactive Approaches:

  • Ethics Committee
  • Staff/Resident/Family Input
  • Unit level huddles/rounds/meetings
    • Environmental
    • Clinical
    • Infection Control
  • Community Care Licensing Information and Reports
  • Partnerships with external sources such as Fraser Health, BC Patient Safety & Quality Council, and Worksafe BC.