Thanks to Jessie Snowdon, Physiotherapist for contributing the below article –
All managers will be acutely aware of the Health and Safety at Work Act 2015 (HSWA) and the responsibilities of, and potential penalties, for PCBUs (persons conducting a business or undertaking).
The HSWA requires businesses to ensure, as far as reasonably practicable, the health and safety of its workers. This includes safe systems of work, equipment, training and monitoring the health of workers. These processes are all included in the policies and procedures designed specifically for residential aged care facilities by HCSL.
Within the residential care industry staff are exposed to significant hazards daily in terms of patient handling and manual handling for kitchen/laundry staff. Moving and handling is a hazardous task – it is repetitive, can involve high force (heavy residents) and frequently involves awkward postures. The likelihood of injury for both care staff and residents is high and the consequences can be serious, meaning that moving and handling is a high risk activity.
When we consider moving and handling in this light, managers need to be confident that they have safe systems. Consider how each resident’s transfer abilities are assessed. How is this documented and communicated? How do you know you have the correct equipment on site and how do you ensure that you have enough equipment in order for staff to be able to access it when they need it?
Our experience shows that often if the equipment is not available many staff will do an unsafe transfer in order to save time. How do you ensure new staff are competent prior to undertaking moving and handling tasks? How do you ensure that existing staff are up-skilled? How do you implement the New Zealand guidelines? And how do you monitor your systems, equipment and training? These are questions all managers should be able to answer.
‘On the Go Physio’ carries out Moving and Handling training in over 15 facilities in Canterbury and offer training to representatives from many others. We offer tailored packages which can include up-skilling your whole team, or training your own moving and handling trainers and assessors. We can review your training and orientation systems and assist in equipment trials. If you are interested in discussing your facilities requirements to help you ensure your staff, and resident’s, health and safety contact us here.
For residential care specific policies and procedures related to safe moving and handling, along with related forms for use, contact HCSLhere.
Contributed by: Jessie Snowdon (Senior Physiotherapist and Director)
https://herculeshealth.co.nz/wp-content/uploads/2025/08/Hercules-Health-02.png00Hercules Healthhttps://herculeshealth.co.nz/wp-content/uploads/2025/08/Hercules-Health-02.pngHercules Health2017-02-08 21:23:002024-09-24 10:54:10Moving and Handling in residential age care
Thanks to Liz Beaglehole – Registered Dietitian for contributing the below article –
With the introduction of the Food Act 2014and the requirement for most aged care facilities to have registered their food control plan (FCP) by March 2018, I thought I would write this article on a common kitchen practice that will require review. This relates to one important key component of food safety.
FCP’s are included in the policy and procedure documentation provided by HCSL specifically designed for residential care facilities.
In many facilities the main meal is served in the middle of the day and the tea meal served at night. The main cook of the day will prepare the tea meal earlier in the afternoon, and then finish his or her shift. The tea meal will be reheated by the afternoon staff and served to the residents.
The process of cooking, cooling and reheating requires careful control of the food safety risk. Many tea options are protein or carbohydrate based; macaroni cheese, egg dishes, savoury mince, chicken options – all of which are high risk foods for bacteria growth.
Foods need to be cooled quickly to avoid time and temperature abuse, which may allow bacteria growth. The guidelines state that when cooling hot cooked foods, the food must cool to at least 21° within the first two hours, and then cool to below 5° in four more hours. Overall, the food must be out of the danger zone (between 5°C and 60°C) within six hours.
A functioning chiller should allow cooked foods to cool within this timeframe. Using domestic fridges that are overcrowded, may mean the cooling guidelines are not met. Using shallow dishes rather than large deep dishes will also allow foods to cool faster.
The food control plan will specify the process the site kitchen must follow with regards to cooling of cooked food. Temperatures during cooling will need to be checked and recorded to ensure the time / temperature targets are met.
Prior to serving, the food must be reheated to above 75°C.
Some sites choose to hold the prepared food hot until service. Food must be held hot at a temperature of at least 60°C, usually in a bain-marie or oven at 70°C. Any food held below 60°C for more than 2 hours, must be thrown out. Note that holding foods hot for this period of time may affect the food quality.
Main Points:
Food safety risk with cooling and reheating foods must be managed with FCP
Cool cooked food to below 21°C in 2 hours and below 5°C in 4 hours
Reheat foods to above 75°C before service
Hold hot prepared foods at 60°C or more
Document food temperatures and any corrective action
Review corrective action implementation to ensure they have been effective
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A very common adverse clinical outcome for residents is unintentional weight loss. It can contribute to a decline in general health, energy, about to heal in relation to skin / wound care and increase the risk of accidents.
Ensuring adequate nutritional intake relevant to the health status for each resident is ultimately the responsibility of Registered Nurses. There has been the perception in some instances that it’s normal to lose weight as people age. While there is an increased tendency to lose weight, it should not be considered normal.
If unintentional weight loss is detected, ensure thorough multi-disciplinary clinical assessment and development of specific short term care plan to define strategies to meet the specified care plan goal. Offering more frequent high energy (high calorie) and high protein snacks and drinks between main meals and instigating the recording of all food and fluid intake should be part of this plan (unless contraindicated). The dietitian can best help guide you through the best nutritional support for each individual resident and their circumstances at the time.
Unintentional weight loss or the undesirable decline in total body weight over a specified period of time is common however should not be ignored as ‘part of ageing’. Sarcopenia (muscle loss in the elderly) is also common however not inevitable and should be addressed through a targeted exercise and balance programme. Light body weight in the elderly have been shown to have a detrimental effect on the resident ability to function and on their general quality of life.
Unintentional weight loss of 3 -5 percent (or greater) in 30 days (or 10 percent in 180 days) must be monitored more closely and a short term care plan must be developed to promote weight loss cessation and implementation of weight management practices. RN’s must ensure they review regular weight monitoring records to identify progressive changes and respond to adverse patterns.
Residents that have been determined to be in later stages of palliative care or receiving terminal cares should be excluded from the need for close monitoring and related care planning related to trying to reverse unintentional weight loss. This is at the discretion of the Registered Nurse in consultation with the Doctor and next-of-kin / advocate / whanau. Discussions will also be had with the resident and the Medical Practitioner regarding the extent or type of tests, investigations and interventions that are desirable. These must be clearly documented in the Care plan evaluation and interventions recorded in the long term care plan and Doctors consultation notes.
Ensure the specific instructions (interventions) are recorded in the care plan for staff to implement on a consistent basis. Ensure these are reviewed at each weight monitoring event (time-frame specified in care plan) and adjust interventions according to weight monitoring outcomes.
If after two weeks of weekly monitoring the weight has not stabilized or started to increase, consult a Dietitian to review the resident and provide recommendations. Ensure any recommendations are followed as directed.
Treat any underlying cause and continue monitoring of weight until it has reached optimum levels in accordance with care plan goals. Return to monthly monitoring of weight at this stage. Those on special diets must be monitored more closely than those residents that are independent with eating and drinking or those that have no identified difficulties which may lead to increased potential for unintentional weight loss.
Case Study:
An 84 year old female resident (Mrs A) with a diagnosis of chronic heart failure and early dementia was noted to be experiencing progressive weight loss. Staff indicated she was able to physically feed herself but often refused to eat, pushing the meal tray away from her. She was able to express her needs to the extent of saying she didn’t want her meal. Staff recorded this in the progress notes however no investigation was done to identify the cause of her refusal to eat. Her weight had reduced at that point to 38kg having had an admission weight of 48kg only six months previously. Staff noted Mrs A was often sleepy during the day and expressed their belief her dementia was advancing. A new Clinical Nurse Lead (CNL) sat down and talked with Mrs A to discover that her mouth wasn’t sore and her dentures were well fitting. There appeared to be no difficulty with her ability to eat or swallow. The CNL consulted with the dietitian to support the assessment process. It was decided that a staff member would sit with Mrs A and gently talk with her as the staff member offered small spoonfuls of food. Mrs A obliged with eating with no resistance or protest and seemed to enjoy her meal. Progressively day after day her intake increased and she seemed to be sleeping less. She had more energy and within a period of one week had shown an 800 gram weight gain. Staff continued with supporting Mrs A with assisting her with her meal and within 6 weeks her weight had increased from 38kg to 41kg. At that time she was no longer sleeping most of the day and had resumed feeding herself. Short term care plans were instigated at the start of this process and more detailed long term care planning and regular assessment was also documented. Family input had been sought to gain a greater understanding of Mrs A’s previous eating patterns and she was able to talk about the foods she enjoyed having with her family. Asking questions about a context such as family meals assisted the staff in gaining more information than if they’d simply asked Mrs A what her favourite foods were. Giving a direct answer to a specific question wasn’t easy for Mrs A however she was able to talk about family meal times which proved a valuable source of information for nursing staff in supporting her. At the end of an 8 week period Mrs A had more energy, was interacting more with others, was sleeping less during the day,appeared happier and was enjoying her meals. She was no longer refusing to eat. It stands to reason that when a person is lacking nutrients, they may actually lose the energy needed to feed themselves. Getting the basics right is a good place to start.
The workshops will initially be held in Christchurch however could be presented in other areas if the interest is high enough. Please feel free to contact us with your requests.
Audits in the aged residential care sector in New Zealand are assessed against their ability to comply with a raft of legislation, standards and contractual requirements.
Below are common findings which continue to be reported on during audits:
Criteria
Gaps in meeting full compliance
Consumer Rights- 1.1
· Complaints management processes not completed as per requirements. Eg; not being logged on the complaints register, time-frames not being met, lack of evidence of resolution.
Organisational Management– 1.2
· Not completing internal audits· Not evidencing completion of regular meetings· Corrective action plans not being developed or completed· Lack evidence of investigation· Lack evidence of family notifications of adverse events· Lack evidence of reference checks at time of employing new staff· Lack of 1st Aid certified staff member on each duty in each work area – this must consider the size, and layout of your building.· No signed employment agreement or job description· Lack evidence of timely completion of orientation· Annual appraisals not completed for all staff
Service Delivery– 1.3
· Lack of timely clinical assessment· Lack of assessment and care-planning related to behaviours of concern (challenging behaviours)· Lack of evidence in progress notes of Registered Nurse input· Lack of evidence in progress notes of interventions from long term care plan· Lack of evidence of family / residents input· Lack of evidence of outcomes from clinical assessments (including InterRai) being used to inform the care plan· Transcribing of medications in care plans· Doctor’s instructions in medical notes not followed / implemented· Wound assessment chart not updated as per wound care plan· Neurological observations not completed following falls where there was a possibility of the resident having sustained a head injury· GP reviews not recorded at time-frames determined in ARRC· Lack of evidence of RN acting on caregivers reporting of adverse health symptoms in progress notes.
Safe and Appropriate Environment– 1.4
· Lack of evidence of medical calibration of equipment· Hoists not checked and verified as fit for use.· Surfaces unable to be cleaned adequately· Non labelled or decanted chemicals· Lack of evidence of hot water temperatures not exceeding 45 degrees
Restraint minimisation and safe practice – 2.0
· No evidence of enabler monitoring· Lack of evidence of incomplete restraint register.
Infection prevention and control– 3.0
· Infection control nurse in care facilities who have not completed training in infection prevention and control and therefore cannot demonstrate relevant knowledge on which to base practice and monitor staff performance.· Not all infections are noted on the infection register. Your policy and procedure should include the internationally recognised definitions for infections on which to base your monitoring. For those of you using the HCSL policies and procedures, these definitions are noted within the Anti- microbial Policy – document code IC1.
Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of your service.
Each winter cardigans or long sleeved tops under uniform tunics appear as part of clothing worn by carers, nurses and other staff providing resident care. Does this practice increase the risk of cross infection?
There are certainly studies that demonstrate that uniforms become contaminated with potential pathogenic organisms including Staphylococcus aureus, Clostridium difficile and Norovirus[1]. It is more difficult to find evidence that links contaminated uniforms with the transmission of pathogens to patients and residents.
Most contamination occurs in areas of greatest hand contact such as pockets and cuffs[2], which may the cause the wearer to re-contaminate their cleaned hands. Long sleeves may also become contaminated with bodily fluids, which then directly contaminate another resident through direct hands on care. This would be a great way to spread around those multi-drug resistant organisms that live in the bowel, such as ESBL, VRE and CRE!
The biggest risk of wearing long sleeves when delivering care involving patient contact is that hand hygiene cannot be carried out effectively. Anyone who has been taught hand washing using the Glitterbug gel and UV light will remember how the wrists were often left glowing, demonstrating that your wrists also get contaminated and need cleaning. In many healthcare facilities across the world, a ‘Bare Below the Elbows’ policy is used to ensure that effective hand hygiene is undertaken. This applies to the use of an alcohol based hand rub or gel, as well as washing with soap and water.
So the next time that you put your cardigan on or come to work with a long-sleeved top, remember that, prior to any patient contact remove the cardigan or roll up your sleeves and perform hand hygiene.
[1] Mitchell et al. Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature. Journal of Hospital Infection, 2015 Aug;90(4):285-92
[2]Loh et al. Bacterial flora on the white coats of medical students. Journal of Hospital Infection, 2000 May;45(1):65-8.
Is a slip off a chair or off the side of the bed onto the floor a fall? Is a ‘controlled lowering’ by a staff member of a resident to the floor a fall?
When recording adverse events such as falls, it’s important for the purposes of consistent reporting and bench-marking that the same definition is used to define a ‘fall’. We suggest using the definition provided by the World Health Organisation (WHO) which states “A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.” The WHO falls prevention guidelines also report that “Globally, falls are a major public health problem. An estimated 424 000 fatal falls occur each year, making it the second leading cause of unintentional injury death, after road traffic injuries.”
Working in aged care related services means you are interacting on a daily basis with those in the high risk category for falls. WHO also report for example, in the United States of America, 20–30% of older people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas. The Health Quality and Safety Commission New Zealand report “for every fall in hospital, there are five in aged residential care and another 40 at home and in the community. Between 2010 and 2012, a total of 200 people fell while in hospital care and broke their hips.“
The HCSL QA online bench-marking includes tracking of falls and falls related injuries so educating your staff to become familiar with the definition is important in ensuring data collected is accurate. Accurate data measurements also allow you to be aware of your start point for quality improvement projects which can then be measured at the end of a project to measure the degree of improvement.
In answer to the questions posed at the start of this article, if we apply the WHO definition, then both should be classified as falls. For those of you using the HCSL policy and procedure system, refer to the Falls Prevention Programme (document CS19) for more information on falls prevention.
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‘Pressure injury’ according to ACC can be classified in some instances as a ‘treatment related injury’ and therefore you may have the option of gaining support / assistance from ACC in relation to treatment of the pressure injury. In their 2011 fact-sheet, ACC noted “Pressure areas are a significant source of treatment injury claims and impact on both patient morbidity and mortality (1). Between July 2005 and March 2011, ACC accepted 506 claims for pressure areas, and notified 45 as adverse events to the Ministry of Health”.
As pressure injuries are a key focus for Ministry of Health (MoH) this year, auditors will be looking closely at the documentation around identification, management, treatment / care planning and evaluation of these events. Ensure you have comprehensive evidence of your clinical management processes.
Also remember when you log a pressure injury into the adverse event reporting system, you include the stage of the pressure injury. In the HCSL QA online system click ‘pressure injury’ in the ‘type of event’ box and then in the box directly under that, you can record the additional detail of the stage of the pressure injury.
The required MoH notification forms can be found here. You will need the resident GP to complete a ACC45 form. Then contact ACC and rather than asking for what you want, ask what they can do to help. If you ask first, you may be missing out on something they could have provided access to.
For more information on seeking support contact Assistant ACC directly or the ACC Contracts Manager – CDHB Email: Leanne.davie@cdhb.health.nz
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On a recent trip to Cambodia and Singapore I visited the older members of the community where they were being cared for and spend their final days. In Cambodia, where there are no formal aged care services; I found the older members of their communities being care for by each other in either family or Buddhist temple settings. The choice is often made by the oldest members of families in Cambodian society to leave home and move into a temple and take on the lifestyle of a Buddhist Monk or Nun.
I was honoured to have had the opportunity to visit these folk and talk with them about their lives and experiences. I asked them if they missed anything about their previous life. The answer when I’ve asked that same question of elder folk in New Zealand has resulted in a long list. These gentle folk smiled broadly at me and told me no, there was not a single thing they missed. Their families still came to visit them. It seemed that was all they needed from life as it was!
In caring for each other these ladies practiced the principles of person-centered care. They were not familiar with the term, were not trained nurses and were not carers who had received formal training. Never the less, they provided care as needed by those receiving it. This was about social housing and accommodation rather than a focus on infirmity, disability or ill health.
On my visit to a nursing home in Singapore, it was inspiring to see the elder ladies sewing staff uniforms and other elder men and women preparing vegetables. These would become meals of the children crèche down the road. These folk talked as they worked together. They were connecting and contributing. Making a difference. They were needed and had value. They held a high status within their community.
In the Singapore Nursing home residents lived in the nursing home in 8 bed units, men segregated from the woman. The sense of connection between residents however was obvious from the numbers of people I saw sitting beside other residents’ beds talking with them, interacting together and chatting as they worked.
There were trained nurses and the Welfare Officer who was a fountain of knowledge talked about person-centered care. The residents’ activities programme was full and could have easily been transferable to any NZ residential care facility.
The terms used were the same as ours but as I looked around I could see the implementation of person-centered care was very different from our interpretation of that type of service. Residents were certainly engaged, appeared happy and well care for.
What struck me however was how different our understanding of the term ‘person centered care’ is and how a society’s culture or organisational policies can mean our practice is very different.
This is an important factor to remember when recruiting staff that have been trained and work in other countries. When you describe something to an applicant you’re recruiting and they say they understand the concept, does it necessarily mean you have the same understanding. The picture in your mind of what the outcome will look like may be very different to their mind-view? Sometimes it pays to ask more questions!
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Medication management relates to section 1.3.12 of the Health and Disability Services Standards and referred to in section D5.4 of the ARRC. There are key reference documents which provide reference at facility level which should be used in conjunction and addition to your organisation policies and procedures. These reference documents are (first two are key for residential care):
Health Practitioners Competency Assurance Act 2003
Medication errors of any type, when reporting through the audit process to MoH HealthCert as part of your audit, will receive a higher ‘weighting’ than other partial or non-attainments. Even a single signature missing off an administration signing sheet may come into this category and mean your audit outcome is diminished. Below are common errors which continue to be made:
Aspect of medication management
Common Errors
Medication charts
Not datedNot signed by the prescriberNot signed by the General Practitioner or Nurse Practitioner at each review (3 monthly)Not legibleAllergies not documented (or inconsistent with other resident documents)Transcribing on medication charts or PRN signing sheetsPRN medication charting does not include ‘indication for use’Medication order does not include time, dose, frequency, route, type etc
Signing sheets
Missed signatures on the signing sheetsOnly one signature (instead of two) on controlled drug administration records and registerPRN medication not signed for accurately
Self-medicating residents
Competency to verify self-medication not signed by prescriberCompetency for self-medication not signed as having been reviewed by prescriber (3 monthly)Staff verification of self-medicating occurred not recorded on a shift by shift basis (as relevant to the individual residents medication order)Not retaining a current list of all medication ordered for self-medicating residents
Storage
Medication not securely stored (also see ARRC D15.3(c) Controlled drugs not entered accurately into Controlled Drug Register (at time of supply or return to pharmacy)Controlled drugs not stored in locked cabinet in locked roomDrug trolley left in common areas unlockedExpired medication continue to be stored on site (should be returned to pharmacy)Medication for resident who has been discharge or deceased remain on siteMedication fridge temperature not monitored / recordedLabels on medication containers not clear / legible
Identification of resident
Photograph not representative of current presentation of resident (photograph should be colour)Photograph of residents not validated regularly
Medication errors
Not reportedNot managed (through an adverse event management process to ensure identification of contributing factor and preventive measures).
Competency
All staff (including Registered Nurses and Enrolled Nurses) involved in medication administration must have first successfully completed a medication competencyAnnual review of medication competencies
If you’re uncertain about the competency of a particular staff member, do not be tempted to sign them off and monitor. The risk is too high for the residents and your organisation. Medication errors can be classified as ‘sub-standard care’ and due to the possible consequences, are at least a moderate risk.
Remember when changing staff around, the key priority is do you have a medication competent staff member on each duty and if controlled drugs are being administered, you need a minimum of two medication competent staff rostered on each duty. Registered Nurses cannot be leaving the ‘hospital’ area of the facility to administer medication in other areas as this leaves the hospital residents vulnerable so this also needs to be factored into your rostering. Refer to the Aged Related Residential Care Contract (ARRC) for further information.
Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of medication management.
Moving and Handling in residential age care
NewsMoving and Handling and the Health and Safety Act
Thanks to Jessie Snowdon, Physiotherapist for contributing the below article –
All managers will be acutely aware of the Health and Safety at Work Act 2015 (HSWA) and the responsibilities of, and potential penalties, for PCBUs (persons conducting a business or undertaking).
The HSWA requires businesses to ensure, as far as reasonably practicable, the health and safety of its workers. This includes safe systems of work, equipment, training and monitoring the health of workers. These processes are all included in the policies and procedures designed specifically for residential aged care facilities by HCSL.
Within the residential care industry staff are exposed to significant hazards daily in terms of patient handling and manual handling for kitchen/laundry staff. Moving and handling is a hazardous task – it is repetitive, can involve high force (heavy residents) and frequently involves awkward postures. The likelihood of injury for both care staff and residents is high and the consequences can be serious, meaning that moving and handling is a high risk activity.
When we consider moving and handling in this light, managers need to be confident that they have safe systems. Consider how each resident’s transfer abilities are assessed. How is this documented and communicated? How do you know you have the correct equipment on site and how do you ensure that you have enough equipment in order for staff to be able to access it when they need it?
Our experience shows that often if the equipment is not available many staff will do an unsafe transfer in order to save time. How do you ensure new staff are competent prior to undertaking moving and handling tasks? How do you ensure that existing staff are up-skilled? How do you implement the New Zealand guidelines? And how do you monitor your systems, equipment and training? These are questions all managers should be able to answer.
‘On the Go Physio’ carries out Moving and Handling training in over 15 facilities in Canterbury and offer training to representatives from many others. We offer tailored packages which can include up-skilling your whole team, or training your own moving and handling trainers and assessors. We can review your training and orientation systems and assist in equipment trials. If you are interested in discussing your facilities requirements to help you ensure your staff, and resident’s, health and safety contact us here.
For residential care specific policies and procedures related to safe moving and handling, along with related forms for use, contact HCSL here.
Contributed by: Jessie Snowdon (Senior Physiotherapist and Director)
‘On the Go Physio Ltd’
PO Box 32 004, Christchurch 8147
Ph: 0800 000 856 or Mobile: 021 030 9061
Food Safety in residential aged care
NewsCooling and Reheating Meals
Thanks to Liz Beaglehole – Registered Dietitian for contributing the below article –
With the introduction of the Food Act 2014 and the requirement for most aged care facilities to have registered their food control plan (FCP) by March 2018, I thought I would write this article on a common kitchen practice that will require review. This relates to one important key component of food safety.
FCP’s are included in the policy and procedure documentation provided by HCSL specifically designed for residential care facilities.
In many facilities the main meal is served in the middle of the day and the tea meal served at night. The main cook of the day will prepare the tea meal earlier in the afternoon, and then finish his or her shift. The tea meal will be reheated by the afternoon staff and served to the residents.
The process of cooking, cooling and reheating requires careful control of the food safety risk. Many tea options are protein or carbohydrate based; macaroni cheese, egg dishes, savoury mince, chicken options – all of which are high risk foods for bacteria growth.
Foods need to be cooled quickly to avoid time and temperature abuse, which may allow bacteria growth. The guidelines state that when cooling hot cooked foods, the food must cool to at least 21° within the first two hours, and then cool to below 5° in four more hours. Overall, the food must be out of the danger zone (between 5°C and 60°C) within six hours.
A functioning chiller should allow cooked foods to cool within this timeframe. Using domestic fridges that are overcrowded, may mean the cooling guidelines are not met. Using shallow dishes rather than large deep dishes will also allow foods to cool faster.
The food control plan will specify the process the site kitchen must follow with regards to cooling of cooked food. Temperatures during cooling will need to be checked and recorded to ensure the time / temperature targets are met.
Prior to serving, the food must be reheated to above 75°C.
Some sites choose to hold the prepared food hot until service. Food must be held hot at a temperature of at least 60°C, usually in a bain-marie or oven at 70°C. Any food held below 60°C for more than 2 hours, must be thrown out. Note that holding foods hot for this period of time may affect the food quality.
Main Points:
Article contributed by:
Liz Beaglehole
NZ Registered Dietitian
Canterbury Dietitians
Email: liz@canterburydietitians.co.nz
Unintentional weight loss
NewsA very common adverse clinical outcome for residents is unintentional weight loss. It can contribute to a decline in general health, energy, about to heal in relation to skin / wound care and increase the risk of accidents.
Ensuring adequate nutritional intake relevant to the health status for each resident is ultimately the responsibility of Registered Nurses. There has been the perception in some instances that it’s normal to lose weight as people age. While there is an increased tendency to lose weight, it should not be considered normal.
If unintentional weight loss is detected, ensure thorough multi-disciplinary clinical assessment and development of specific short term care plan to define strategies to meet the specified care plan goal. Offering more frequent high energy (high calorie) and high protein snacks and drinks between main meals and instigating the recording of all food and fluid intake should be part of this plan (unless contraindicated). The dietitian can best help guide you through the best nutritional support for each individual resident and their circumstances at the time.
Unintentional weight loss or the undesirable decline in total body weight over a specified period of time is common however should not be ignored as ‘part of ageing’. Sarcopenia (muscle loss in the elderly) is also common however not inevitable and should be addressed through a targeted exercise and balance programme. Light body weight in the elderly have been shown to have a detrimental effect on the resident ability to function and on their general quality of life.
Unintentional weight loss of 3 -5 percent (or greater) in 30 days (or 10 percent in 180 days) must be monitored more closely and a short term care plan must be developed to promote weight loss cessation and implementation of weight management practices. RN’s must ensure they review regular weight monitoring records to identify progressive changes and respond to adverse patterns.
Residents that have been determined to be in later stages of palliative care or receiving terminal cares should be excluded from the need for close monitoring and related care planning related to trying to reverse unintentional weight loss. This is at the discretion of the Registered Nurse in consultation with the Doctor and next-of-kin / advocate / whanau. Discussions will also be had with the resident and the Medical Practitioner regarding the extent or type of tests, investigations and interventions that are desirable. These must be clearly documented in the Care plan evaluation and interventions recorded in the long term care plan and Doctors consultation notes.
Ensure the specific instructions (interventions) are recorded in the care plan for staff to implement on a consistent basis. Ensure these are reviewed at each weight monitoring event (time-frame specified in care plan) and adjust interventions according to weight monitoring outcomes.
If after two weeks of weekly monitoring the weight has not stabilized or started to increase, consult a Dietitian to review the resident and provide recommendations. Ensure any recommendations are followed as directed.
Treat any underlying cause and continue monitoring of weight until it has reached optimum levels in accordance with care plan goals. Return to monthly monitoring of weight at this stage. Those on special diets must be monitored more closely than those residents that are independent with eating and drinking or those that have no identified difficulties which may lead to increased potential for unintentional weight loss.
Case Study:
An 84 year old female resident (Mrs A) with a diagnosis of chronic heart failure and early dementia was noted to be experiencing progressive weight loss. Staff indicated she was able to physically feed herself but often refused to eat, pushing the meal tray away from her. She was able to express her needs to the extent of saying she didn’t want her meal. Staff recorded this in the progress notes however no investigation was done to identify the cause of her refusal to eat. Her weight had reduced at that point to 38kg having had an admission weight of 48kg only six months previously. Staff noted Mrs A was often sleepy during the day and expressed their belief her dementia was advancing. A new Clinical Nurse Lead (CNL) sat down and talked with Mrs A to discover that her mouth wasn’t sore and her dentures were well fitting. There appeared to be no difficulty with her ability to eat or swallow. The CNL consulted with the dietitian to support the assessment process. It was decided that a staff member would sit with Mrs A and gently talk with her as the staff member offered small spoonfuls of food. Mrs A obliged with eating with no resistance or protest and seemed to enjoy her meal. Progressively day after day her intake increased and she seemed to be sleeping less. She had more energy and within a period of one week had shown an 800 gram weight gain. Staff continued with supporting Mrs A with assisting her with her meal and within 6 weeks her weight had increased from 38kg to 41kg. At that time she was no longer sleeping most of the day and had resumed feeding herself. Short term care plans were instigated at the start of this process and more detailed long term care planning and regular assessment was also documented. Family input had been sought to gain a greater understanding of Mrs A’s previous eating patterns and she was able to talk about the foods she enjoyed having with her family. Asking questions about a context such as family meals assisted the staff in gaining more information than if they’d simply asked Mrs A what her favourite foods were. Giving a direct answer to a specific question wasn’t easy for Mrs A however she was able to talk about family meal times which proved a valuable source of information for nursing staff in supporting her. At the end of an 8 week period Mrs A had more energy, was interacting more with others, was sleeping less during the day,appeared happier and was enjoying her meals. She was no longer refusing to eat. It stands to reason that when a person is lacking nutrients, they may actually lose the energy needed to feed themselves. Getting the basics right is a good place to start.
Residential care education workshops
News, ServicesWe provide a number of aged residential care education workshops throughout the year. Topics include:
The workshops will initially be held in Christchurch however could be presented in other areas if the interest is high enough. Please feel free to contact us with your requests.
Audit Tips – Common findings in audits
NewsAudits in the aged residential care sector in New Zealand are assessed against their ability to comply with a raft of legislation, standards and contractual requirements.
Below are common findings which continue to be reported on during audits:
Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of your service.
For more assistance with this contact us.
Are your staff increasing risk of cross infection?
NewsCardigans – a potential vector of infection?
Each winter cardigans or long sleeved tops under uniform tunics appear as part of clothing worn by carers, nurses and other staff providing resident care. Does this practice increase the risk of cross infection?
There are certainly studies that demonstrate that uniforms become contaminated with potential pathogenic organisms including Staphylococcus aureus, Clostridium difficile and Norovirus[1]. It is more difficult to find evidence that links contaminated uniforms with the transmission of pathogens to patients and residents.
Most contamination occurs in areas of greatest hand contact such as pockets and cuffs[2], which may the cause the wearer to re-contaminate their cleaned hands. Long sleeves may also become contaminated with bodily fluids, which then directly contaminate another resident through direct hands on care. This would be a great way to spread around those multi-drug resistant organisms that live in the bowel, such as ESBL, VRE and CRE!
The biggest risk of wearing long sleeves when delivering care involving patient contact is that hand hygiene cannot be carried out effectively. Anyone who has been taught hand washing using the Glitterbug gel and UV light will remember how the wrists were often left glowing, demonstrating that your wrists also get contaminated and need cleaning. In many healthcare facilities across the world, a ‘Bare Below the Elbows’ policy is used to ensure that effective hand hygiene is undertaken. This applies to the use of an alcohol based hand rub or gel, as well as washing with soap and water.
So the next time that you put your cardigan on or come to work with a long-sleeved top, remember that, prior to any patient contact remove the cardigan or roll up your sleeves and perform hand hygiene.
[1] Mitchell et al. Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature. Journal of Hospital Infection, 2015 Aug;90(4):285-92
[2]Loh et al. Bacterial flora on the white coats of medical students. Journal of Hospital Infection, 2000 May;45(1):65-8.
Contributed by:
Ruth Barratt
Infection Prevention & Control Advisor
infectprevent@gmail.com
Falls – When is a fall not a fall?
NewsIs a slip off a chair or off the side of the bed onto the floor a fall? Is a ‘controlled lowering’ by a staff member of a resident to the floor a fall?
When recording adverse events such as falls, it’s important for the purposes of consistent reporting and bench-marking that the same definition is used to define a ‘fall’. We suggest using the definition provided by the World Health Organisation (WHO) which states “A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.” The WHO falls prevention guidelines also report that “Globally, falls are a major public health problem. An estimated 424 000 fatal falls occur each year, making it the second leading cause of unintentional injury death, after road traffic injuries.”
Working in aged care related services means you are interacting on a daily basis with those in the high risk category for falls. WHO also report for example, in the United States of America, 20–30% of older people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas. The Health Quality and Safety Commission New Zealand report “for every fall in hospital, there are five in aged residential care and another 40 at home and in the community. Between 2010 and 2012, a total of 200 people fell while in hospital care and broke their hips.“
The HCSL QA online bench-marking includes tracking of falls and falls related injuries so educating your staff to become familiar with the definition is important in ensuring data collected is accurate. Accurate data measurements also allow you to be aware of your start point for quality improvement projects which can then be measured at the end of a project to measure the degree of improvement.
In answer to the questions posed at the start of this article, if we apply the WHO definition, then both should be classified as falls. For those of you using the HCSL policy and procedure system, refer to the Falls Prevention Programme (document CS19) for more information on falls prevention.
Pressure Injuries – ACC may be able to help
News‘Pressure injury’ according to ACC can be classified in some instances as a ‘treatment related injury’ and therefore you may have the option of gaining support / assistance from ACC in relation to treatment of the pressure injury. In their 2011 fact-sheet, ACC noted “Pressure areas are a significant source of treatment injury claims and impact on both patient morbidity and mortality (1). Between July 2005 and March 2011, ACC accepted 506 claims for pressure areas, and notified 45 as adverse events to the Ministry of Health”.
As pressure injuries are a key focus for Ministry of Health (MoH) this year, auditors will be looking closely at the documentation around identification, management, treatment / care planning and evaluation of these events. Ensure you have comprehensive evidence of your clinical management processes.
Also remember when you log a pressure injury into the adverse event reporting system, you include the stage of the pressure injury. In the HCSL QA online system click ‘pressure injury’ in the ‘type of event’ box and then in the box directly under that, you can record the additional detail of the stage of the pressure injury.
The required MoH notification forms can be found here. You will need the resident GP to complete a ACC45 form. Then contact ACC and rather than asking for what you want, ask what they can do to help. If you ask first, you may be missing out on something they could have provided access to.
For more information on seeking support contact Assistant ACC directly or the ACC Contracts Manager – CDHB Email: Leanne.davie@cdhb.health.nz
Person-centered Care depends on your recruitment processes
NewsOn a recent trip to Cambodia and Singapore I visited the older members of the community where they were being cared for and spend their final days. In Cambodia, where there are no formal aged care services; I found the older members of their communities being care for by each other in either family or Buddhist temple settings. The choice is often made by the oldest members of families in Cambodian society to leave home and move into a temple and take on the lifestyle of a Buddhist Monk or Nun.
I was honoured to have had the opportunity to visit these folk and talk with them about their lives and experiences. I asked them if they missed anything about their previous life. The answer when I’ve asked that same question of elder folk in New Zealand has resulted in a long list. These gentle folk smiled broadly at me and told me no, there was not a single thing they missed. Their families still came to visit them. It seemed that was all they needed from life as it was!
In caring for each other these ladies practiced the principles of person-centered care. They were not familiar with the term, were not trained nurses and were not carers who had received formal training. Never the less, they provided care as needed by those receiving it. This was about social housing and accommodation rather than a focus on infirmity, disability or ill health.
On my visit to a nursing home in Singapore, it was inspiring to see the elder ladies sewing staff uniforms and other elder men and women preparing vegetables. These would become meals of the children crèche down the road. These folk talked as they worked together. They were connecting and contributing. Making a difference. They were needed and had value. They held a high status within their community.
In the Singapore Nursing home residents lived in the nursing home in 8 bed units, men segregated from the woman. The sense of connection between residents however was obvious from the numbers of people I saw sitting beside other residents’ beds talking with them, interacting together and chatting as they worked.
There were trained nurses and the Welfare Officer who was a fountain of knowledge talked about person-centered care. The residents’ activities programme was full and could have easily been transferable to any NZ residential care facility.
The terms used were the same as ours but as I looked around I could see the implementation of person-centered care was very different from our interpretation of that type of service. Residents were certainly engaged, appeared happy and well care for.
What struck me however was how different our understanding of the term ‘person centered care’ is and how a society’s culture or organisational policies can mean our practice is very different.
This is an important factor to remember when recruiting staff that have been trained and work in other countries. When you describe something to an applicant you’re recruiting and they say they understand the concept, does it necessarily mean you have the same understanding. The picture in your mind of what the outcome will look like may be very different to their mind-view? Sometimes it pays to ask more questions!
Medication Management Audit Tips
NewsMedication management relates to section 1.3.12 of the Health and Disability Services Standards and referred to in section D5.4 of the ARRC. There are key reference documents which provide reference at facility level which should be used in conjunction and addition to your organisation policies and procedures. These reference documents are (first two are key for residential care):
Medication errors of any type, when reporting through the audit process to MoH HealthCert as part of your audit, will receive a higher ‘weighting’ than other partial or non-attainments. Even a single signature missing off an administration signing sheet may come into this category and mean your audit outcome is diminished. Below are common errors which continue to be made:
If you’re uncertain about the competency of a particular staff member, do not be tempted to sign them off and monitor. The risk is too high for the residents and your organisation. Medication errors can be classified as ‘sub-standard care’ and due to the possible consequences, are at least a moderate risk.
Remember when changing staff around, the key priority is do you have a medication competent staff member on each duty and if controlled drugs are being administered, you need a minimum of two medication competent staff rostered on each duty. Registered Nurses cannot be leaving the ‘hospital’ area of the facility to administer medication in other areas as this leaves the hospital residents vulnerable so this also needs to be factored into your rostering. Refer to the Aged Related Residential Care Contract (ARRC) for further information.
Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of medication management.