Multiple issues and comments.

We are in a very delicate and difficult period at the moment with the Royal Commission fueling concern and complaints. The organisation must respect this state of affairs and take a pro active response to it.

Complaints are always going to occur and  we do have systems in place but in recognition of the heightened atmosphere we have to use our in place mechanisms and adopt extra ways of coping.

Complaints need to be raised to a number one priority. This means looking more closely at the ones we have and looking for ways to detect them in advance plus reacting to both the known and perceived ones with more vigor.
One way of detecting them is from the smaller complaints e.g. around bell call times. Family, if aggrieved or concerned will report smaller problems first. These should not be to many in number but provide an opportunity for the care manager to discuss the immediate concern and make inquiries about any other broader concerns. This same approach should be used to concerns around the meals and room and patient care.I would go so far as to listing each complaint in a record for the hostel etc. and requiring that the staff have had a family meeting or discussion. If further points of concern are raised it must be drawn to the attention of management and follow up visits weekly arranged with the family and resident to ensure that all issues have been addressed and satisfied. Further the family should be encouraged and made comfortable to come forwards early if new problems arise.
This will not stop new issues due to behavioral or medical problems arising but it will guarantee both a good reputation inside the hostel for helpfulness and reduce the distress the family feels when incidents do arise. Provided we try to do the right things and we also do have insurance, together that will get the resident and staff through difficult times.

Medication and the new electronic medication system. * and a recent complaint.

The comments made have exposed the problems that have always existed in the medical medication system. Medicines have many uses but many side effects. All medicines are poisons but we use them where their good outweighs their harm.There is great responsibility in giving drugs and medications to residents. A wrong dose, an omitted dose, a wrong patient and there is a possible severe risk that could perhaps have been avoided.

This is why doctors have had to sign medication charts personally and write each one out legibly by hand. Nurses administering them had to know the drugs, know the doctor, ensure themselves that the dose seemed correct and then sign, often with a counter signature, to ensure the right dose gets to the right person at the right time.

Advantages for the new system were that
medication orders would be more legible [note by law they were already legible],
the difficulty in reading multiple medication charts.
Missed medication signatures [?] [note by law they were always meant to be signed].
Reducing staff time giving out medication.
Eliminating the need to fax G.P.’s and Pharmacy.

The ecase MMS [medication management system] has not to date shown these advantages. The very medications that re most problematical, Drugs of addiction, antibiotics, variable dose drugs like insulin and warfarin and all the prns cannot be put on the system. As well as long term injectables which poses a problem with the psychotropic medications.

Instead there is now an extra layer of computer generated drug charts sitting side by side with the unchartable drugs. Further these drug charts cannot be accessed or modified by the doctors easily as yet. As I forecast 20 years ago, 10 years ago, 2 years ago and last meeting the technology in the medical field is very slow at catching up to that expected in the rest of the world. The programs available everywhere have not been fully developed and reactive.

On the positive side the lists that are available are both readable and easy to send on to doctors and hospitals and pharmacists.Technology will catch up as we use more computer generated forms. We do not need to throw the baby out with the bathwater.

However the problems that existed before still exist now and are slightly worse with the new charts because we are now more reliant on the Doctor/Nurse/Pharmacist nexus than before. In an age where doctors are not available to or will not visit nursing homes to authenticate the drug charts and worse, initial the changes that occur. Putting our staff and residents at risk.

We need to reinforce the use of the old drug charts and regimes strictly for all the computer unchartable drugs. We need to open up lines of communication with the doctors and pharmacists [pay them more?] and work on ways to get the doctors in town to team up to help. One suggestion in this new era could be to open a clinic up on site or employ a GP or 2 by Shepparton Villages.


Pain management.

A third major issue. Pain is different from person to person and as people age communication of the pain can be very difficult, especially with dementia. Pain can be chronic in many elderly people due the the various types of arthritis. Fractures occur more commonly. Cancer develops and is a cause of ongoing increasing pain needing palliative care. Documenting the pain is both difficult and time consuming. Pain can also be quite variable making it difficult to quantify. Some patients do not wish to take treatment.Some people become addicted to the medications. Different charting methods exist. Treatments can be medical or non medical.
The three parameters though are the nursing staff, the resident and the family.
The staff are perceptive to pain in residents and need to be listened to when they raise the subject. Residents will usually complain when they feel their pain as at a level and intensity that needs treatment. Family are very sensitive to suffering in their loved ones and again need to be listened to and involved in the treatment where possible.If any of these three conditions are met then using a pain tool can be an extra help to all but it is the clinical judgement and patient/family concerns that need addressing more than the pain tool.
This is an area where other indicators like call bell numbers, incontinence, reduced mobility and pressure ulcers can be both useful for diagnosing the pain and also diagnosing those residents and families who need to be more involved in the care to reduce complaints.
PRN medication is not just an overused choice that can be reduced by other measures. PRN medication is vitally important in managing fluctuating arthritis pain and headaches. It is essential in palliative care to reduce breakthrough pain. There is always a trend to push regular medication for pain relief on elderly people only to find a few days later that they do not wish to take it. This leads to calls to the doctor to amend it to regular and then back to PRN. In my experience it is better to leave it to PRN  unless there is documented regular use for 4 weeks.

Dementia and Dementia training.

Complaints and feedback6 provide feedback is too long at 21 days needs to be within 24 hours or immediately.

Risk map residents at risk

failure to identify and report an incident [complaint]

Internet impeding access to medical records    scripts

Aged Care issue date Jan 2015 ACQSC

Make it easy to complain

QCG Framework SVN.

Minimum restraint Open discolsure