Table 4 Audit of residents records pre-implementation (n = 15) and post-implementation (n = 15). Different resident charts were audited pre and post, and thus, direct comparisons were not possible

Documentation

● In both phases, there was full compliance for assessments of nutritional status.

● There was close to full compliance for recording of weight, safety for eating alone/swallowing status, risk of ulcers/pressure sores and record of dental/oral assessment.

● Discussions/feedback from the resident or their family (dependant on resident’s dementia stage and ability to indicate preferences) were documented in both phases.

● All residents whose charts were reviewed received a medication review in the previous year.

● From pre to post, there were more reviews documented with decision-making about continuation/discontinuation of medication.

● More discussions about medications with resident’s family and with residents who are capable of having a discussion were documented.

● More reviews of antipsychotic prescriptions documented post-implementation.

● More medication reviews of safety to receive medications and covert drug administration documented post-implementation.

● Evidence of adoption of an alternative pain assessment tool for one resident was observed in the post-implementation analysis. Documented evidence of daily frequency of assessment was also noted post-implementation in four of the charts.

● General details about the pain assessment were recorded for all participants, which was the same as the observed pre-implementation audit.

● For site, type and location assessments, there was no change, and for one, i.e. the number of pains, there was an increase in documentation.

● The HCP approach to the pain and treatment plan is the same as pre-implementation with all residents having undergone these assessments.

● Medications and side effects, ongoing assessments and effectiveness of treatment, overall, since the implementation of EBG, there is less evidence of documentation of ongoing assessments and actions to remedy side effects. There was an increase for prescription for breakthrough pain.

● As with the pre-implementation audit, all but one of the residents were unable to be involved in their pain treatment. For the one resident post-implementation audit that could interact with the MDT team, there was no record of any discussions with them about their treatment.