Accreditation Bulletin #7 – Resident Care Experience Part 2

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BULLETIN #7 – Resident Care Experience

Part 2: Delivering Safe & Reliable Care

Delivering Safe and Reliable Care is a subsection under Resident Care Experience as one of the Accreditation Themes. It focuses on ensuring our residents’ needs are met by providing safe and reliable individualized care. The Resident Care Experience theme includes 7 Required Organizational Practices (ROPs) that must be met to successfully complete Accreditation which will occur October 17 – 21, 2022. Here are the remaining 3 ROPs (part 2 of 2):

ROP #5: Resident Identification

Surveyor Question: At Menno Place, how does the team confirm that residents receive the service or medication intended for them? How many resident identifiers are required?

Answer:  In partnership with residents and families, there must be at least two person-specific identifiers used to confirm that resident receive the service or procedure intended for them (i.e. – medication administration).

Evidence:  How do we do this?

  • Menno Place has a Resident Identification policy RCS 2.09
  • Staff are required to verify residents by 2 identifiers before providing any service or care to a resident, often with the involvement of the resident or family.
  • Menno Home/Hospital uses the following identifiers:
    1. Photographs of residents found in Point Click Care profiles, eMAR (Home) & medication boxes (Hospital), Point of Care, Resident room doors (Home), and inside room (Hospital), etc.
    2. Consult with another team member who is aware of the resident’s identification
    3. Chart labels/profile includes name, PHN, birthdate, etc. is used in conjunction with above two.

ROP #6: Information Transfer at Care Transitions (transfer in and out of care home)

Surveyor Question: How does the team ensure that information is transferred in an accurate and timely manner at transition points?
Answer:  Information relevant to the care of the resident is communicated effectively during resident transfer in and out of care.

Evidence:  How do we do this?

  • Internal transfer: ensure timely and accurate transfers between units include a combination of verbal and written information. Examples include: the electronic health record, the paper health record, verbal report nurse to nurse.
  • Shift change/breaks: verbal and written reports are used for shift changes and breaks. Written reports include electronic documentation and shift summary forms.
  • External transfer: several practices to ensure accurate and timely transfer of information includes faxing, sending completed transfer sheets, telephone calls or giving verbal information face to face, including standard transfer sheet located in resident records and standardized physician discharge summaries.
  • Care conference: collaborate and interdisciplinary meetings with electronic records to verify and plan actions and goals of care and quality of life with resident, family/ caregiver, and team members.

ROP #7: Infusion Pump Safety

Not applicable to Menno Place

Thank you for your support in making this Accreditation Survey another successful one!