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Chapter 5 Findings
In another set of documentation a nurse had documented that staff respect the
resident’s wishes for care:
“Patient informed that his wishes will always be taken on board.”
However, overall this element of resident autonomy was not evident in 87%
(n=33) of documentation.
Chart 5.10: Element 2
Care plans are negotiated. Family are involved.
87%
5.7.3 Element 3: Residents Delegate Care Needs
This element was judged to be evident if there was evidence of promoting
resident capacity, and that residents subsequently delegated care based on that
capacity. The criterion stated that a resident’s level of independence would be
documented and the level reviewed over time. Specific evidence was required in
relation to what a resident can and cannot do for themselves, e.g. “can brush own
hair, can do zips but not buttons”.
13%
The analysis of the documentation revealed a lack of specificity in relation to
what residents could or could not do for themselves. While the level of
Evident
Not Evident
independence was usually documented at the initial admission assessment, it was
noted to lack a detailed account of what a resident could or could not do for