Aged Care Quality and Safety—Royal Commission—Interim report: Neglect—Volume 3: Appendices

Royal Commission into Aged Care Quality and Safety

Interim Report: Neglect

Volume 3 Appendices

© Commonwealth of Australia 2019

ISBN:

978-1-920838-88-1 (print)

978-1-920838-87-4 (online)

With the exception of the Coat of Arms and where otherwise stated, all material presented in this publication is provided under a Creative Commons Attribution 4.0 International licence. For the avoidance of doubt, this means this licence only applies to material as set out in this document.

The details of the relevant licence conditions are available on the Creative Commons website as is the full legal code for the CC BY 4.0 licence .

The terms under which the Coat of Arms can be used are detailed on the Department of the Prime Minister and Cabinet website (www.dpmc.gov.au/government/commonwealth coat arms).

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Table of Contents

Appendix 1: Community Forums 3

Introduction 3

Bankstown community forum 5

Bendigo community forum 8

Wollongong community forum 11

Maidstone community forum 13

Broome community forum 16

Townsville community forum 18

Adelaide community forum 21

Brisbane community forum 23

Rockhampton community forum 25

Appendix 2: Roundtable Discussions and Participants 31

Appendix 3: Witnesses 41

Appendix 4: Exhibits 53

Appendix 5: Post-hearing Submissions 175

Appendix 6: Service Provider Visits 179

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Appendix 1: Community Forums

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Appendix 1: Community Forums Introduction The Royal Commission is holding public forums to hear directly from members of the Australian community about their experiences of, and ideas about, aged care. The community forums provide an opportunity for Australians to tell their stories or share their views with the Royal Commission in a more accessible setting than formal hearings.

Participants at community forums provide extremely valuable information to support the Royal Commission’s inquiry. Participants hear about the work in progress. They offer their ideas on current aged care services and what is important to consider for the future.

At the time of completing this Interim Report, the Royal Commission had held nine community forums, with 167 people giving statements. We look forward to holding further community forums in the months to come.

Preparing for community forums The Royal Commission promotes community forums widely: on its website; through its email list; via national and state-wide advocacy bodies; and through advertisements in local media. Where appropriate or necessary, additional promotion may occur. For example, the Royal Commission engaged a local culturally knowledgeable organisation to assist with promoting and delivering the community forum in Broome in June 2019.

Members of the public can register to attend or speak by phone or online. There is time for about 20 speakers at each forum. There are often more people interested in speaking than the time allows, and speaking places are allocated primarily based on the order of registration.1

The Royal Commission’s Community Engagement team contacts each person who has expressed an interest in speaking. For those who speak, Royal Commission staff offer further guidance to help them make the most of the opportunity to speak.

For those who do not secure a speaking place, the Community Engagement team provides a number of alternative options to engage with the Royal Commission. These include making a submission, speaking to staff at the forum or through the phone line, or providing written feedback at the forum.

1 Where there is high demand for a speaking position, the Royal Commission’s priority is to enable older people or their family members and friends with direct experience of aged care to make a statement. When this information is provided, it assists in the selection of speakers. The Community Engagement team may also assign one speaking position per group or family.

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Structure of community forums Each community forum begins with a brief opening statement from the attending Royal Commissioner, outlining the purpose of the Royal Commission and providing an update on recent activities.

Speakers make statements of up to five minutes and are encouraged to provide written versions of their statements. At the end of each community forum, the Commissioner present sums up what participants have said.

Royal Commission staff assist speakers and other participants with any questions. Counselling and support staff are available to assist participants who experience distress as a result of telling their story or hearing the stories shared by others and can also refer participants to services for longer term assistance. Interpreters are available to speakers, when possible. At the Broome community forum, for example, there were two interpreters, one of whom spoke Kimberley Kriol while the other spoke eight different local Aboriginal languages. Where possible, Auslan interpreters and hearing loops are available to assist deaf and hearing impaired participants.

Participants can also provide written submissions or other materials to staff at the forum. They can also share their written views on a question sheet, which asks:

• What are the current problems or challenges in aged care?

• What can be done to achieve high quality, safe, person-centred aged care into the future?

• How can we build a culture of dignity and respect for older people?

The question forms also include space for any other comments.

Staff are available before the forum, during the break, and after the forum to speak to members of the public about their experiences or to answer questions about the Royal Commission.

Members of the media may attend but are advised not to identify participants or attribute statements without a person’s specific agreement.

Community forum experiences The community forums give a direct and immediate picture of the community’s experience of aged care. There have been a number of recurring themes and stories:

• substandard care—speakers gave many examples of poor care, medication misuse, adverse events, and neglect of older people’s needs

• dignity and respect—the importance of maintaining dignity and respect for people in aged care, and numerous instances of disrespectful and dehumanising treatment

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• disempowerment in the complaints process—in particular, families described their numerous efforts to have care improved, their resultant feelings of powerlessness and distress, and their frustration with the complaints processes

• staffing issues—staffing levels, training of aged care staff, remuneration and attitudes to aged care as a career

• providing culturally safe care

• guardianship issues and enduring powers of attorney misuse • financial distress—the costs of care and difficult financial decisions arising from aged care.

While the forums conducted so far raised similar themes each was distinctive, shaped by the location, the specific stories, and the participants.

Many participants found the community forums an emotional experience. They expressed anger, frustration, grief, and deep sadness, both about their own experiences and the stories told by others. Some participants also expressed gratitude about positive experiences and their hope about opportunities for improvement.

In many cases, forum participants spontaneously shared stories with each other, supported each other through the experience of speaking at the forum and expressed gratitude to their fellow community members for sharing their stories.

Bankstown community forum The first community forum was held on 1 March 2019 in Bankstown Sports Club at Bankstown in Western Sydney (NSW), with Commissioner Briggs attending. There were 22 speakers and about 270 people attended. While two of the speakers described positive experiences with aged care services, the majority raised concerns about the quality and safety of aged care.

Speakers provided examples of poor medication management, serious pressure injuries, falls and inadequate hydration and nutrition. A speaker described finding her mother-in- law with extensive bruising:

[W]e saw heavy bruising on her face. When we got her home I undressed her and saw…she was black from one end of her to the other…My mother-in-law said that she had been left alone in the bathroom in the shower chair and had fallen onto the floor…I wrote a detailed letter to the Director of Nursing and was told that ‘old people bruise easily’. I suppose they do if you drop them onto concrete.

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Another speaker talked about finding her mother dehydrated in a residential care facility:

I was told that they have not been able to get [her] to take in any fluids…Nor had they called a GP to examine her. She was barely speaking by then and prior to that week she had been walking by herself, assisted by a walker…She was in hospital for… nearly five weeks—being treated for severe dehydration as well as several infections and pressure sores…The hospital found out that my mother had not toileted for up to five days, hence her stomach pains. There were limited or no records kept of [her] fluid intake…the facility was not even aware that she had developed pressure sores.

A personal care worker employed in home care explained that she is often the only person who goes into the house. She commented that she was trained to note changes in people’s mental and physical health, but that she could not do this properly during 15- minute visits.

One speaker described the risk to the mental health of nurses and her own depression after being bullied when unable to meet unrealistic work expectations. Several speakers raised concerns about the adequacy of training of aged care staff members, particularly in caring for people with dementia.

Recurring concerns about the quality of care included:

• overuse of antipsychotic medication for dementia patients to ‘keep them controlled, quiet, managed and, in some instances, tolerated’

• relying on a limited number of continence pads rather than providing assistance with using the toilet.

Several speakers described poor reactions by aged care providers when responding to concerns and complaints. One speaker described being informed by the Chief Executive Officer of the facility that his mother had been abused, and then told, ‘to move on and get over it’. Another speaker reflected on cultural differences:

It’s an all-Chinese nursing home, containing staff and residents who are culturally reluctant or scared to complain…[the air conditioning] was not fixed for years—senior management told us no-one had complained and they did not know, which we find hard to believe…residents were at times left sweltering in 30-plus degree heat…one resident’s bathroom measured 40 degrees on a heatwave day.

Several speakers mentioned that residents and family members are fearful of making complaints due to possible repercussions.

Two speakers from the deaf community raised concerns about the availability of appropriate assistance to navigate the aged care system. In particular, they spoke about the importance of access to Auslan interpreters, particularly when making important decisions about their care, as well as when dealing with wills and bequests.

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A number of speakers had experience as nurses or personal care workers, including in aged care. They raised particular concerns about nursing staff members being diverted from care to administration. One speaker said:

A registered nurse’s job is to monitor change in patients but there is constant pressure to do paperwork and get funding.

Another said:

Managers are too busy doing paperwork and they’re not on the floor. Get rid of paperwork and prove what you can do. It’s not about sitting at a computer while somebody needs to go to the toilet.

There was cynicism expressed about behaviour of some aged care providers. For example, one family member heard from an aged care worker that they were to ‘make up and exaggerate’ the behaviour and needs of residents to get more funding subsidies, and another described the ‘fudging’ of numbers of staff recorded on duty. One speaker saw changes in staffing before a visit from the regulator:

employees would come out of the woodwork to make it look better, right before a visit.

Several spoke of their difficulties in accessing services, including through My Aged Care, and of the long waiting lists for home care services and inadequate support for family carers.

My financial paperwork was lost four times. January 2018 My Aged Care cancelled mum’s home care package [and] did not advise why, after many phone calls [I] was advised [they] did not have my financial paperwork. I then personally handed it in, they lost it, then I had faxed it and it was lost yet again and then I faxed it a second time…Finally it was in the system April 2018.

A personal care worker employed in home care explained that she is often the only person who goes into the house. She commented that she was trained to note changes in people’s mental and physical health, but that she could not do this properly during 15-minute visits.

Two speakers from the deaf community raised concerns about the availability of appropriate assistance to navigate the aged care system. In particular, they spoke about the importance of having access to Auslan interpreters, particularly when making important decisions about their care, as well as when dealing with wills and bequests.

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Several also spoke of financial stress around aged care, including a speaker who reflected on the particular experience of older women facing homelessness. One family member gave up her employment to care for her mother, and was experiencing severe financial hardship:

when we have given up our careers, spent our super, when we are close to 60 and cannot return to our former careers, we have nowhere to turn to for help. Carers are the silent sufferers of the global dementia pandemic.

A number of speakers emphasised the importance of respect and dignity for older people as a foundation for aged care:

Elderly people were once part of the fabric of society and just because they have become ill and frail and no longer independent, does not mean they deserve less care of respect. It should be the opposite.

The final speaker spoke about the importance of person-centred care, and encouraged a conversation about love in aged care:

Residents want someone to listen to them, for someone to sit on their bed and have someone hold their hand.

Bendigo community forum The second community forum was held on 5 March 2019 in Bendigo Town Hall at Bendigo in Victoria, with Commissioner Briggs attending. There were 20 speakers and about 250 people attended.

Several speakers suggested that people in the community lack knowledge about aged care services and about how to navigate the very complex system. One speaker, a volunteer who supports families, explained that an applicant may have to speak to nine different services to access care:

I trust this complicated process will be simplified.

One speaker described her struggle to obtain community services to help her keep her father, who had dementia and feared residential care, at home. She was unable to access residential respite for a break. She was also unable to access home-based palliative services at the end of her father’s life, when he was admitted to a palliative care unit:

As carers, we carry the burden of the system and funding failures…in the absence of system reform, these failures will continue.

Another speaker described a broken resource system. He said that he found it necessary to accept residential care for his father while waiting for home care services, but his father subsequently became despondent and died. Another speaker expressed concerns about the significant gap in respite care services in the community, where lack of relief from

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caring can lead to ill health for the family carer. One speaker suggested that concern in the community about entering residential care can lead to a reluctance to plan for care needs and services in later life.

The quality of residential aged care services received particular focus. One speaker considered the physical care in his mother’s facility as adequate, but described the transition to care with loss of connection to friends and community as ‘like stepping off a cliff’. The speaker said that there was a total absence of assistance to help his mother adapt. He observed that staff members are stretched thinly and unable to respond to the loneliness that residents experience, or to give a personalised response to their care needs:

Aged care facilities should be homes first, workplaces second, and institutions third.

One speaker spoke about both his parents, who live in the same facility. The speaker described how his father, affected by a stroke, would hear his wife, who has dementia, wailing down the hallway. His father would ring the bell for help:

No-one would come…he felt useless.

As a result, the speaker explained, the family organised for private care to be provided for 11 hours a day, six days a week. Over a two-year period, they advocated to the facility for their mother to be weaned off her medication. This eventually occurred, resulting in her laughing and smiling, and generally being happier. The speaker described person-centred care as more than physical care, with a need to focus on a person’s wellbeing:

We took matters into our own hands. Their home is where they should feel safe and loved.

Other speakers also provided examples of inadequate care of people with dementia. One speaker described how the manager of an aged care home insisted that her mother be lifted with a lifting machine due to mobility issues, which caused her mother to become withdrawn. Physiotherapy at the facility only provided for pain relief and not, despite requests, re-enablement. The family invested in private physiotherapy and equipment for 18 months. Their mother was able to walk again and her cognition improved:

We were able to do this for mum because we never gave up. It should be about living, not waiting to die.

Two separate speakers stated that injuries to family members were not detected in a timely fashion, resulting in undetected pain and increased infection. Several described significant mistakes being made in the medication provided to people. In one instance, the medication was meant for a resident in the adjoining room. In another, medication mismanagement resulted in the person not eating. This led to significant weight loss.

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One speaker advocated for changes in legislation to protect vulnerable people in aged care services who receive injuries as a result of poor care. Another speaker described the everyday neglect of her mother with respect to hygiene and nutrition. The speaker’s mother subsequently died of sepsis. The speaker said she felt the facility treated her like a troublemaker when she raised care issues:

I was bullied and intimidated by management…before my mother passed away I was told that she was taking up too much of the staff’s time.

A number of speakers raised the issue of adequate staffing. One speaker, calling for mandatory staff levels, said that staff are constantly rushed off their feet. Another believed that poor staffing levels place residents at risk because staff struggle to carry through basic care tasks and are stressed:

Very hard working, well-intentioned staff doing the best they can in challenging circumstances.

Several spoke about the need for more staff skills and knowledge, with different speakers making the following suggestions:

• capability improvements through more training • the screening of staff for qualifications and personality suited to caring

• closer monitoring of staff who carried out their care tasks poorly

• staff training in dementia care, such as understanding that pain may be a cause of distress

• greater emphasis on staff giving attention to the information provided by family members, who know the person and their needs.

Another concern was that of reduced care options for younger people. One younger person with a disability described her struggle to stay at home, which required her periodic admittance to a residential aged residential care facility. She described this experience as confronting and humiliating, with her dignity and privacy not respected, and inferred that she would end her life if that became the only option ahead:

If my funding and supports do not…enable me to stay at home, I’ve made a decision not to go to aged care. I’m not going there again.

One person spoke of the incompetent management of diabetes and a lack of assistance with meals for their sister, who had Down’s syndrome. The speaker’s sister died of pneumonia. Earlier, the family had been so distressed that they considered kidnapping her from the facility but believed that they would be in trouble with the law.

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Other speakers described their distress at the type and limited amount of care for their family member and in particular the lack of personalised holistic care:

To watch what she’s going through is life-destroying.

Several speakers described the need to become advocates on behalf of a family member to ensure that basic care needs and rights were met. One speaker explained that they felt they had no voice in representing the needs of their family member. To be able to speak up on behalf of their family member receiving residential care, they had needed to educate themselves about the Aged Care Act 1997 (Cth) and about rights:

We fought for our dad, because he mattered, because people matter, because human rights matter.

Many speakers acknowledged the grief, anxiety and emotional trauma experienced by families:

Our story is filled with heartache, like many of you here.

Several speakers spoke of priorities in aged care being out of balance. One suggested that the facility providing care to their family member focused on meeting organisational needs rather than patient needs, while another speaker expressed concern about the financial motivations of aged care organisations:

The thing is, there should be care before profit.

Wollongong community forum The third community forum was held on 13 March 2019 in WIN Stadium at Wollongong in New South Wales, with Commissioner Briggs in attendance. There were 20 speakers and about 187 people attended.

Speakers discussed person-centred care, care of residents with dementia and palliative care. A particular theme was the need for a skilled and kind workforce as a pathway to quality and safe care for older people in aged care facilities. This included calls for improvements in the training of registered nurses, enrolled nurses and personal care workers. Some speakers referred to the need for improvements in provider leadership.

The main workforce issues that speakers identified related to training needs, a requirement for increased numbers of staff for residents, and better pay rates. A general practititoner who had worked in aged care for 22 years raised workforce as a ‘crucial issue’:

We need more registered nurses, better trained aged care registered nurses, and better paid aged care registered nurses. We also need better trained enrolled nurses and better trained carers.

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Another speaker made several points about improving the status, training and salaries of all workers in aged care, including:

• requiring registered nurses to have postgraduate qualifications in gerontology and reward them accordingly

• recommending senior classifications for registered nurses with specialist qualifications in wound care, continence, palliative care and so on

• providing incentives for care workers to increase basic qualifications to Certificate 4 level and renumerate accordingly

• considering Certificate 4 as entry level qualification in the future.

A number of speakers emphasised the importance of better training, with particular focus on dementia, trauma, and behavioural management:

Beyond the RNs, the enrolled nurses and carer staff are usually poorly skilled in aged care specific challenges such as dealing with challenging behaviours in dementia, such as agitation or aggression. Because of this, there is often a push from both RN and other staff to use strong pain medications or sedation or even antibiotics when they are not necessary in order to do ‘something’ about behaviours.

Speakers provided examples of poor person-centred care, ranging from waiting lengthy periods for care packages, lack of focus on prevention of harm from falls, problems with ulcers or oral health issues, dependence on staff, and random care episodes that did not meet their relative’s needs of timely assisted meals and help with hygiene, going to the toilet and hydration. One speaker stated that each aged care facility needed to have, or have access to, at least one specialist in palliative care. Another speaker described a need for leadership in practice with end-of-life care, which should extend beyond the last few days and hours. Two speakers referred to the need for gender-specific personal care.

Several speakers raised the issue of carer stress associated with lack of communication from staff. These speakers worried about possible adverse consequences if they spoke to the facility on behalf of their relative, including the possibility of them being isolated or banned from visiting the facility:

There must be a recognition that the services provided by carers such as myself, are saving the country a fortune, but often at great personal cost…The knowledge that we could access a home where we would be expertly, gently and lovingly cared for in our community, would relieve so much stress and greatly enrich the remaining years of our lives.

Another theme for many speakers related to improved service integration, including better processes for communicating and resolving issues. One speaker suggested better service integration and coordination between governments, as operators can be very cautious due to over-regulation. Similarly, one speaker reported that the National Disability Insurance Scheme had suggested going to My Aged Care, but My Aged Care then said that they couldn’t help. Another speaker suggested that negotiating the network of government and provider red tape was more stressful than her husband’s dementia. Another

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speaker stated that the system assumed, incorrectly, that people had family support. What the community needs, one speaker suggested, is a transparent, dependable and affordable system, with personalised support to navigate the bureaucracy.

One speaker described how a family member was neglected, abused and forgotten when the family expected that she would be comfortable and safe. She died within six weeks of entering the aged care facility. A different speaker cited an example of unprofessional behaviour where confidentiality and privacy were ignored at a service provider meeting. Another speaker referred to the ‘forgotten Australians’, people who as children were placed into institutional or other out-of-home care. The speaker recognised that these people would face particular challenges if they returned to residential care as an older person. A different speaker suggested the need for video cameras in common areas and residents’ bedrooms, or for families to have cameras to monitor activities of daily living.

Several speakers who had worked, or continue to work, in aged care reflected on their experiences. This included being told not to get attached to the residents. They described the increasing complexity of caring for residents, including the need to provide higher levels of care, to deal with complex medications, and to work with limited preparation or training. A health professional observed that there is no standardised information technology system in residential aged care facilities. A different speaker commented that some things had not changed: the high workloads, the shortage of staff, and the pay. Another speaker stated that they had serious concerns for their safety and that of their fellow workers, compounded by management’s attitude.

Maidstone community forum The fourth community forum was held on 3 May 2019 in White Knight Receptions Maidstone, at Maidstone in Victoria, with Commissioner Briggs and Commissioner Tracey in attendance. There were 18 speakers and about 260 people attended. Three young disabled people, together with their family members or carers, spoke about the experience of living in residential aged care. Other speakers focused on inadequate care, staffing ratios, complaints processes, and the rights of residents and carers. Several people spoke about the experiences of younger people in residential aged care:

My daughter spent 12 months in aged care at age 18 after a craniotomy for to a brain tumour and strokes. At 28 [years] she was unable to speak or move…Our observations and reading notes accessed through Freedom of Information convince us that aged care is no alternative for young people...She often waited half an hour for a worker to arrive when she buzzed…Her room was next to the pan room and the smell was sickening at times. Friends stopped visiting. It was a depressing place. A staff member pulled us aside one morning and told us that some of the staff were not treating her well. We already knew that but any concerns fell on deaf ears. Residents were not being treated equally. We observed bullying and neglect of ‘difficult’ residents who weren’t silent and compliant.

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One young person, assisted in her verbal communication by a support worker, described living in a nursing home for six years. She explained that people are constantly screaming and that there is no stimulation. She finds it hard to come up with ideas of what to do, and just sits quietly on her own. She explained that life has changed so much for her. She used to like to paint and to be outside: ‘now all that is unreachable’. As a vegetarian, she finds there is lack of food choices, and that the food is the same every day. With the National Disability Insurance Scheme plan, she used to have up to 500 hours of therapy, but now only has 60 hours:

They said no one would be worse off under the NDIS but that is not my experience.

This speaker spoke of a desire to end her life, saying she would do so if her arms would allow it.

A speaker in her thirties spoke with the assistance of communication device. Following a stroke after an operation, this speaker’s only option, because of a lack of disability funding, was an aged care facility. From her 18 months in the facility, the speaker described having little autonomy about decisions such as her daily routine, activities and food. She found some staff patronising, and said they treated her as being unable to make her own decisions. According to this speaker, the most important thing was for staff ‘to truly listen and support us to drive the process of our lives’. She believed that better trained and better educated care support workers were required to meet complex needs.

One speaker spoke of her experiences with home care services:

I have travelled from rural New South Wales to speak today because I am disgusted by the corrupt, inconsistent behaviour of providers and their care staff…

This speaker explained that she had changed providers because workers lied about hours worked and because transport was not provided. However, the situation did not improve:

the next provider I went to was unreliable. Staff did not turn up for necessary showers…sometimes no staff for a couple of days and that meant no personal care on those days…so I changed providers again…every statement with that provider was incorrect…

The speaker expressed concern that she would be forced into residential care, defeating the whole purpose of home care allowing her to remain in her own home: ‘I am blessed I have a family who care but many don’t.’

One speaker noted what they regarded as inadequate or poor residential care, with insufficient focus on the quality of life of residents:

I have observed my mum sitting in her seat for her meal and have it put in front of her without any acknowledgement or even a smile…my impression and feeling of this facility is one of a business on a budget waiting for turnover with little thought to promote the quality of care for these aged people in their final years.

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The speaker said that aged care should not just be ‘a place to die’.

Another speaker raised concerns about his wife’s care in a residential facility, including dirty toilets and the misuse of medication. He stated that the User Rights Principles should offer protection from all types of abuse. However, the Principles were ineffective in supporting rights of care recipients because the facility treated them ‘flippantly’:

the ‘Charter’ is in reality a toothless tiger. It is not in its current form affording protection to the people it purports to defend…In the absence of a ‘charter’, what does the resident have in their corner? Who speaks for these poor souls, some with dementia, when their basic rights are denied them? The government complaints department just took the word of the facility as fact and were unhelpful.

Another speaker found the local advocacy service to be very supportive but observed that the service had little power to make changes.

A representative of Carers Victoria, a state-wide advocacy group for carers, spoke about the need to acknowledge relationships between family carers and people for whom they care. This speaker stated that care provided by family and friends is the backbone of the Australian aged care system, and noted that carers need acknowledgement as people with their own needs. The speaker said that the obligations on providers is not consistent with the Carers Recognition Act 2012 (Vic). In addition, carers, family and friends are notably absent from the new Charter of Aged Care Rights. The speaker concluded that improved recognition of carers would promote safer and better quality care for people using the aged care sector.

Some speakers connected better care with higher levels or ratios of staff to residents, and with improved training. One speaker said that lack of staff led to neglect. This speaker considered the Australian Government’s complaint, accreditation and advocacy systems to be ineffectual. She described starting a petition to mandate skilled staff to resident ratios, which had to that point attracted 312,000 signatures. Another speaker advocated for better training, including specific care for lesbians and other minorities because aged care staff members do not know how discrimination works. One more speaker commented that staff ratios need to be informed by complexity of the needs of the residents. She had observed staff members who wanted to help but did not have the necessary skills. Another speaker suggested that the aged care system of safety is ‘impotent’ and would benefit from a focus on the sort of safety models that exist in health care systems.

Several speakers suggested empowering families to assist with care, along with the need for the community to engage more with older people living in aged care. Some speakers suggested ways to bring younger people into aged care roles through credits towards Higher Education Contribution Scheme (HECS) debt and for universities to look beyond Australian Tertiary Admission Rank (ATAR) scores for community involvement. According to one speaker, all personal care workers should be registered with the Australian Health Practitioner Regulation Agency. Another speaker thought staff should have a university qualification to provide dementia care and that salaries should reflect that. Another speaker commented on the need for appropriate rewards and a clear long-term career path for staff.

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Finally, a speaker commented that the ‘government needs to stop giving aged care licences to unsuitable people who lack empathy, compassion, experience and the values needed to be entrusted with the care of our elderly’.

Broome community forum The fifth community forum was held on 19 June 2019 in the Broome Civic Centre at Broome in Western Australia, with Commissioner Briggs in attendance. The Broome community forum commenced with a Welcome to Country provided by Jimmy Edgar, a Karajarri man and descendent of a Yawuru Elder. There were 13 speakers, predominantly Aboriginal and Torres Strait Islander people. About 50 people attended. Two speakers had an additional person stand up with them to make their statement. A number of the speakers travelled long distances across the Kimberley region to share their experiences about aged care in remote areas of Western Australia.

Speakers told about the need for cultural safety, enabling people to fulfil their cultural responsibilities to their families and communities and to have the choice to remain on Country. They emphasised the importance of treating Elders with respect. Speakers referred to Elders as ‘knowledge holders’ and ‘living treasures’.

One speaker commented that the Stolen Generations Elders did not want to go back to institutionalised care:

They were removed from everything from a very early age and re-programmed; let us not put them through this trauma again toward the end stage of their lives.

Another drew on his history as an Aboriginal Elder and Japanese descendant to tell the story of multi-racial Australia and shed light on the fear that older people with such experiences have about further institutionalisation.

Speakers provided examples of substandard care and neglect, financial abuse of elders, and a sexual assault.

Several people commented on issues and challenges facing Aboriginal people due to low income, the high costs of food and services in regional areas, living below the poverty line, and the need for safe houses. One speaker said that the economic status of Aboriginal people needed to be looked into when considering how to deliver aged care services in remote areas.

According to one speaker, many Aboriginal people have a fear of moving out of their homes and going out of their Country to a strange place, particularly because residential aged care services are not culturally well informed.

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Several speakers commented on the need for providing services for Aboriginal people by Aboriginal people. As one person put it:

There could be more done around training and/or upskilling more Indigenous people in Palliative Care so that when and if our Stolen Generation Elders do need to go to these Aged Care Facilities, the least we can assure them is that there will be familiar faces for them.

If we have more local people trained and employed across all levels, not just in junior roles, we may start to see a difference. We still need these facilities in our communities but we also need them to be run better so our Elders see it as an option and not a sentence.

One speaker suggested implementing measureable outcomes into service agreements that reflected the cultural requirement and the complexities of living remotely. Another speaker suggested the implementation of a cultural audit.

Speakers commented on aged care issues, including access and equity, the complexity of systems, assessment barriers, and the need for face-to-face services with local providers. One speaker explained that they were unable to navigate myGov, even though they have a Masters and a Bachelor of Applied Science. This speaker questioned how an Aboriginal person who has English as a third language would navigate this sort of online system:

ACAT is not an easy process and is used more as a barrier than a pathway to accessing care. Language is exclusive and not easily understood.

One speaker advised that some people choose to not access care because they do not understand the packages or because of the high costs.

One speaker, whose mother is happy with the care received from her home care package, commented that the communication from the centralised service was confusing and lacked empathy. She considered that there needed to be more focus on ensuring that people understood the system, not helped by the use of acronyms in monthly statements. Another speaker said that fees for a person in residential care were raised without informing Centrelink to increase deductions, causing additional difficulty to a grieving daughter:

After losing her mother and going through ‘sorry time’, the carer (daughter) was advised that there was an outstanding invoice. There are always many other service providers that are involved in the overall care of our Elders but communication between these services and the relevant family member is not always as good as it could be. We also need to ensure that families are not further traumatised when their loved ones pass away with issues that should be dealt with as they arise.

Other people made the point that many people are not eligible for services and may fall through the cracks, and noted limited services for young people on disabilities. One speaker said the Aged Care Funding Instrument does not take into account the

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complex needs of Aboriginal people in regional, rural and remote areas. Another speaker said support is inadequate and that some services written into agreements and contracts do not happen.

Several speakers talked about challenges with respite, and one speaker explained that the delivery of dementia services to Aboriginal and Torres Strait Islander populations faced serious challenges.

One speaker commented on the complaints process:

maybe have a more open process where complaints can be made to an independent party so they are addressed.

Several speakers praised the work of many professionals who work in aged care in remote and regional services in the community.

Townsville community forum The sixth community forum was held on 18 July 2019 in Rydges Hotel South Bank at Townsville in Queensland, with Commissioner Briggs in attendance. There were 20 speakers, with about 180 people attending. Speakers provided examples of inadequate care, poor medication management, and inadequate care coordination. Some people talked about the gaps in care for Aboriginal and Torres Strait Islander people, the Forgotten Australians, people from culturally and linguistically diverse backgrounds, and people with a disability.

One speaker talked of the inadequate care her father received prior to his death in a residential facility:

My family considers his death was premature as a result of the aged care facility not providing adequate care for him. My father was found on the floor on a number of occasions when he had fallen, sometimes only wearing an adult nappy and shirt, and was eventually found with a broken ankle. We will never know how many times he fell nor how long he was left on the floor each time as the record keeping at the facility was not accurate.

This speaker described how the family lodged a complaint just before her father’s death, but was advised after his death that no further action would be taken by the Complaints Commissioner. Family members found this extremely upsetting. A new process was initiated following a request for a review and the report identified significant concerns impacting all residents:

The audit indicates that there are insufficient staff, staff do not have time to attend to residents’ needs, and processes are not effective to ensure that staffing is maintained to meet residents’ needs...how many times can a facility not meet Standards before there are serious consequences?

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One speaker described the lack of emotional care for her mother ‘in terms of her loneliness and social engagement. Frequently, she was left isolated and ignored in her room’. The speaker’s mother also received poor personal care:

Mum endured the most distressing lack of, and inconsistencies with, toileting support. I had growing concerns when Mum’s pullup was frequently soaked with urine when I would change her for bed. The nursing home then committed to a toileting schedule. However, toileting support never lasted for more than two consecutive days before it petered out. During this supposed toileting support, a diary entry for June 2015 says ‘Mum had long pants on inside out and back to front, no pull-up on, was smeared with faeces on her hands and needed a shower’ and in July says ‘Arrived at 2pm— toilet filthy, faeces on toilet seat (cased on the rim of the seat), faeces on all towel in the room and wearing a filthy pull-up.’

This speaker also described visiting her mother on a weekend when being informed that she had been prescribed morphine for back pain:

On arrival at Mum’s room, she was lying across the middle of the bed with her legs hanging over, crying out in pain and repeatedly saying that she ‘wanted to die’. She could not move from that position. After 10 minutes, I asked for the doctor to attend earlier and when he didn’t arrive I asked a care worker to call an ambulance. She said she wasn’t allowed to, so, at 9:28am, I called an ambulance myself and mum was taken to hospital. She had a broken back.

This speaker considered that a camera should be in every room ‘when a family requests it, or mandated for residents’ rooms where there are no family who visit’. She considers there needs to be the establishment of ‘an authority, with real power, for families to report concerns, and not condone and ignore them’.

Three speakers regarded getting an Aged Care Assessment Team visit, a Home Care Package, accessing Residential Aged Care facilities, and using the My Aged Care Portal as complicated:

My mum is elderly and has health issues, there is no way that she would have been able to do all of the work involved with getting Dad a Nursing Home place within the 35 days outlined by the hospital staff as well as deal with the reality that she has ‘separated’ medically from her husband of 54 years, the grief and emotions that she is experiencing every day is mentally and physically exhausting.

From memory, approximately four years ago my husband was approved for a level 4 care package. I received notification about six months after his death last year that a package was available. How does that happen in a system which has sifted through everything about us? I felt guilt, frustration and sadness as he diminished despite our best efforts.

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How our aged persons are best served by the online ‘My Aged Care’ and a telephone helpline baffles me. Great people when you can get in touch with them but an awful system! The shortcomings were a constant source of angst for me. I can imagine how older, more technically challenged people must struggle.

On the question of care for Aboriginal and Torres Strait Islander people, speakers referred to specific needs and the gaps they have encountered in aged care services. One speaker stated that although cultural values from some places do not fit with Aboriginal and Torres Strait Islander people, they have to ‘just put up with it’ because there are not many affordable options available to them in their own parts of the country. These situations, the speaker suggested, would not be tolerated in mainstream nursing health care.

Another speaker noted that English is not a first language for some Aboriginal people, and may be a third or fourth language. These people may have a cohort of identified health and ageing conditions, including hearing issues, dementia, confusion, communication issues, assertiveness issues, grieving for their family and Country, and so on. They may find themselves ‘in a foreign routine where enclosure inside a building, noise and rush, rush, rush is the norm’:

Too often there is not enough resources to take them outside to even connect with Country, sunshine, fresh air, nature, sounds of birds etc. I have found far too often, their culinary preferences are unavailable on the menu and many residents of Indigenous heritage are too often, not made a priority and are left in a soiled bed (their budget didn’t allow for more incontinent aids etc.), to wait, last to receive care or left for the next shift—there is not enough assertive presence in the facility to assert for them.

Australia’s care and standards for Indigenous peoples in aged care facilities are, in general, a disgrace to our nation and need monumental review in the near future not the ‘who knows when’ future… they are human beings who deserve the same rights and entitlements as any other Australian.

A number of speakers considered that the needs of culturally and linguistically diverse residents in residential aged care was neglected. Some people raised communication as a major issue for culturally and linguistically diverse people: ‘care ultimately rests a lot on communication’. One speaker noted that some people with dementia may revert to using their mother tongue, leaving them unable to voice their needs.

Other issues raised included the need for understanding of cultural perspectives and a requirement for service providers to receive cross cultural training and cultural awareness training. One speaker talked about isolation and loneliness and cultural inhibitions, while another suggested that, ‘Nursing homes could be marked as suitable for people from a particular ethnicity or culture.’ Another speaker saw the culturally and linguistically diverse background of care staff as adding to the challenges in the care environment:

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Too often care delivery is delivered by ‘caring’ carers with a limited command of English. There is a high proportion of non-English speaking background staff in Aged Care and whilst their intentions are usually honourable, there are issues with their standard of knowledge and skills to enable them to deliver the standards of care expected in Australia.

One speaker highlighted issues facing Forgotten Australians, who had an ‘entrenched mistrust of systems’ due to their previous experience in institutions. A return to institutionalised living could trigger ‘loss of power and independence again’ and memories of past trauma. The speaker stated that such people needed extra support following their entry into residential aged care facilities, not just ‘a tick and flick type form about their wellbeing treatment’.

A disability advocate made the following comment:

I have witnessed in my eight years attending residential aged care facilities in Townsville and surrounding areas, insufficient staff levels to adequately care for the residents both aged and young, and more so for those with disabilities. There is also a gap in the skills of the staff and there are some staff who should not be working in the sector, sadly.

Several speakers advocated for closed-circuit television cameras in aged care facilities, indicating this would assist with the quality and safety of care. However, one speaker acknowledged this would not be an easy road, while another speaker suggested it should be on family request. Another speaker thought closed circuit television cameras could perhaps be considered for residents who did not have any family visits.

Some speakers raised instances of medication mismanagement, such as mistakes that caused falls or drowsiness or where residents had to wait over an hour for pain relief.

One speaker commented that the facility where his mother lives is driven by an economic imperative, despite being not-for-profit. The economic objective is met, the speaker said, through cutbacks to staffing and to the quality of staff because of the shift from a regular to a casual workforce. This same speaker spoke of medication mismanagement, missed meals and the facility’s inability to know the special needs of his mother or even respond to her call bell. He reported that his mother had said she wanted to die and had looked with interest at euthanasia laws.

Adelaide community forum The seventh community forum was held on 12 August 2019 in the Adelaide Town Hall at Adelaide in South Australia, with Commissioner Tracey in attendance. There were 20 speakers and about 400 people attended. Many of the speakers referred to instances of harrowing care that caused distress to both residents and their families, and the need for more empathetic, better qualified or better trained carers.

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Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Five speakers talked about their experience at the Oakden Older Persons Mental Health Service. One speaker, who had a family member at the previous Oakden facility, stated:

The impact of reality that this could be or could have and probably will happen to a loved one or you at some stage is felt by everyone.

Another speaker strongly advocated for preventing what they had experienced ever happening again:

Since the horrors of Oakden have aired, I have worked closely with the current SA Government on various projects to ensure that what Dad went through was not in vain. I would prefer that he not be remembered as a victim of abuse, but rather be instrumental in the catalyst for change.

Many speakers questioned the empathy, qualifications, training and pay levels of the carers and staff they encountered in aged care. One speaker stated:

It seems that for many of the staff, it is just a job with no responsibility or care. There are some that are very capable, sympathetic, fun loving and caring; however, and unfortunately, these seem to be the silent minority. If only they could have more influence on their colleagues, this might improve but it seems they are so busy doing the right thing for the residents they just don’t have the time.

We can plead for higher staff numbers. We can call for a higher nurse to carer ratio, but I don’t believe this will in itself change much. I believe if everyone performed their duties competently and diligently then even with the existing staffing there would be a large improvement in performance. One of the critical elements currently missing is accountability. Too many of those involved in providing care for the aged are not held accountable for their areas of responsibility. This must change and that change must come from the top down to those providing first level care. The top being Facility Managers, CEOs and even the Federal Minister.

Another speaker said:

It’s getting harder and harder for everyone to care for our elderly in the way they deserve when you don’t have time to care for residents properly. We used to have time to talk with residents, sit down and do their nails, not just clean them, and take them for walks. But now, we don’t have the time. The carers are run off their feet and don’t have the few extra minutes to get to know their residents.

One speaker was disturbed by the way the Aged Care Funding Instrument is calculated, suggesting that because providers do a self-assessment, there is self-interest.

Individual speakers made reference to power of attorney, the Office of the Public Advocate and the South Australian Civil and Administrative Tribunal. One speaker stated that after the family had repeatedly asked the facility questions about their mother’s medication, the speaker lost guardianship to the Office of the Public Advocate. Another speaker stated that their parent was vulnerable and that there were family abuse issues, but that the

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Appendix 1 Community Forums

South Australian Civil and Administrative Tribunal had refused to appoint an independent guardian. A different speaker said that a social worker had made a submission for the public trustee to look after the affairs of the speaker’s parent, even though the family had a valid power of attorney. One woman stated that her husband had frontal lobe dementia and that facility staff had blocked the family from visiting him. The family reported this situation to the South Australian Civil Administration Tribunal.

Other speakers raised issues with complaints processes. One speaker stated that deaths had occurred which should have been avoided through proper care and the facility did not have a complaints system, which led to anger among family members. Another speaker said they had complained to all staff at a particular facility, all the way up the chain, as well as to the Australian Competition and Consumer Commission, the Australian Health Practitioner Regulation Agency, the police, and elsewhere. One person said that they complained to the Aged Care Quality and Safety Commission about a particular

medication being given to a family member, and that after 48 hours the drug was ceased. Another person stated that the Commission was not working effectively following its last restructure.

One speaker believed his parents, who were both in a high care facility, chose to end their own lives by not eating, drinking or taking medications. He stated that they had died alone in their room. The facility did not inform the family what was happening and told the family they had 24 hours to clear the room.

Another speaker said there was a need for regulation in balanced with compliance, the need for profit and the need for individual human dignity.

An Aboriginal woman described herself as ‘so angry’, but said ‘anger won’t fix this’:

Our elderly come to you to live safe, comfortable, happy lives ‘til they die. Let’s make these places somewhere we would all be happy to let our mums die irrespective of race or what they did in their younger years. Every elderly person in Australia has the right to die with dignity, grace and respect.

Two of the speakers had nothing but praise for the facility where their family member resided.

Brisbane community forum The eighth community forum was held on 19 August 2019 at the Brisbane Convention and Entertainment Centre in South Bank at Brisbane in Queensland, with Commissioner Briggs in attendance. There were 20 speakers and about 260 people attended.

Speakers focused on a range of topics, such as the following: challenges with My Aged Care (including the complaints systems, both current and past); guardianship aspects and the use and misuse of enduring power of attorney; dementia care; the cost of care; challenges for people with a disability; people from culturally and linguistically diverse backgrounds; people with a vision impairment or blindness; and the importance of family advocacy.

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One speaker commented on what he called ‘the entire debacle’ of his experience with My Aged Care and the Aged Care Assessment Team (ACAT):

It is a very complicated system and difficult to understand even for a university educated person—I despair for the elderly with no one to help or advocate for them.

The bureaucracy around aged care services is beyond comprehension; and the waste of money and resources filling in paperwork aggravating. My Aged Care does not focus on the person needing the care, but on their systems. Once, the wait time for an assessment to get someone to assist him to put a plastic bag on his arm prior to a shower, when his arm was in a cast, was 6 weeks, by which point the cast would be off.

From a ‘consumer’ perspective, My Aged Care is simply woeful. Not one of the many people to whom I have spoken has ever said ‘let me have a look into this and try and find a solution’. They tick a box, and hang up.

One speaker, who had experienced challenges with enduring power of attorney, the aged care complaints system and the Queensland Civil and Administrative Tribunal, said:

My mother suffered for eight years, and died in the most horrific and painful way. This could have been prevented if she was cared for properly. My life will never be the same again.

Another speaker said they had lost confidence in the Complaints Commission because they received an acknowledgment of the complaint but with another person’s complaint information. According to the speaker, the complaint assessor was difficult to contact and unresponsive, requiring the speaker to follow up and undertake significant research to prove staff were lying.

One speaker highlighted poor responses from the aged care complaints system, along with insensitivity to the needs of Forgotten Australians:

My understanding of the role of an Aged Care Commission is to uphold high standards for all residents in care, however my experience was that they did not want to know about any troubles experienced by my mother, a ‘Forgotten Australian’. I was passed from person to person and the process was made exceedingly difficult and traumatic for me.

One speaker identified access barriers for deaf older people:

Most Deaf Australian Elders are able to access free medical interpreters for their limited health, allied health and GP appointments through National Auslan Booking Services known as ‘NABS’. However, the Deaf Australian Elders are having greater difficulties and uncertainty over their futures for receiving support services and facilities for the Deaf needs…due to gaps and breakdowns of government funding systems in different areas, such as Health, Medicare, NDIS/NDIA, My Aged Care,

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Appendix 1 Community Forums

Seniors support, Hospital (Public and Private Hospitals) and Education (for further study if the Deaf Australian person age 65+ wishes to study at TAFEs/colleges or universities)…These Deaf people from the Australian Deaf Elders group have to be fully reliant on their hearing adult children or relatives or senior hearing signing family members to provide free basic sign language interpretation for their simple appointments/errands even (though) they are entitled to free qualified Auslan interpreters with NAATI licences.

Several speakers described the failures in care experienced by vulnerable family members in care. One speaker said that her mother’s needs were not understood and there were constant instances of inadequate care, such as unsafe positioning, becoming chilled when in front of an air conditioner, hygiene issues such as soiled clothes, and rough handling resulting in bruising.

Another speaker believed there was a lack of humanity in the institutional delivery of aged care, and emphasised the importance of family advocacy to ensure that the needs of the older person was met:

The ‘aged care’ we have experienced could be characterised as often lacking in ‘care’. These shortfalls place a heavy burden on us to always be ‘on guard’—to always double-check, to play detective, to second-guess. They are thieves stealing away our time with our dad, forcing us to spend it scrutinising the very institutions entrusted with his care.

Rockhampton community forum The ninth Royal Commission into Aged Care Quality and Safety community forum was held on 20 August 2019 in Callaghan Park Functions and Events Centre at Rockhampton in Queensland, with Commissioner Briggs in attendance. There were 12 speakers, with approximately 60 people in attendance.

Many speakers told of their concerns about residential care facilities, including the lack of activities and the lack of choice for residents. They also provided examples of sub- standard medical care and neglect. One speaker noted the lack of activities, apart from ‘TV all day’. Another speaker explained how her mother had to shower at 6am in winter: ‘She was told that she didn’t have a choice in the matter that was when the personal care was done.’ Another speaker said that their mother had lost 24 kilograms while in recovery at a residential aged care facility, noting that the family supplemented meals almost daily. Another speaker said that:

The residential aged care facility withheld all recovery treatment to my friend and there was no consequence for this.

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One family member said that their loved one had a pressure sore in their sacrum area. The wound deteriorated ‘and smelt bad’. The wound was subsequently identified as a severe septic infection that required strong intravenous antibiotics and a 10-day hospital visit.

Another speaker stated that her friend’s death was referred to the Coroner as a reportable death:

But where is protection for elderly if there are no real consequences for residential aged care facilities when treatment is withheld? My friend experienced multiple care failures and there was total neglect.

Speakers commented on the Aged Care Quality and Safety Commission, including the complaints process:

We made a complaint to the Complaints Commissioner. It was an intimidating process and the family felt let down. We were told the Complaints Commission could not help with the problems. Why would they say this? The Complaints Commission did not check back with the aged care facility and there was no follow-up to see if matters were addressed. The family needed to monitor care and if they didn’t, our father would not be alive.

Another speaker suggested that:

ACQSC should be able to identify criminal behaviours and have people responsible prosecuted. This will go a long way to building a culture of respect for the elderly.

Speakers also questioned the rights charter and legal system. One speaker suggested that the Charter of Aged Care Rights should mean that ‘older people are protected and we don’t have to be here’. Another person stated that the legal system ‘doesn’t respect and protect elders’.

One speaker discussed the affordability of care and related financial issues:

More communication is needed between facilities, residents and families. Forums are needed for families to advise them about choices when a resident’s savings have run out.

According to some speakers, older people want to stay living at home, with concerns raised about transition care and home care packages:

Home Care Packages don’t cut the mustard. Level 4 HCP doesn’t provide anywhere near the 24 hour a day support need for people living with dementia.

There is an inability to get home care packages and palliative care packages in a timely way.

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Speakers commented on staffing issues in aged care, including the lack of staff, staff being underpaid, staff not having a career path and staff receiving inadequate training.

A dentist highlighted how poor dental health had an impact on overall health, noting the need for oral care plans. The speaker stated that university trials had shown that dental treatment in residential aged care facilities and in home care reduced costs. Another speaker discussed food safety for ‘robust food safety programs, as safe and nutritious food is an important aspect of aged care’.

Several speakers commented upon the need for inclusive access to services, including the need for aged care facilities to focus on the whole person. Another speaker emphasises the importance of respect:

Mum is not the same person as she was 50 or 60 years ago—or even 2 years ago— but she is still an amazing woman with a lot to contribute. All older people deserve respect.

The question of respect also arose in the context of end-of life-care:

We need quality end-of-life care. We need medication available in RACF to provide pain relief and help families to understand loved ones’ needs.

One speaker said that Aged and Disability Advocacy was very helpful. Another speaker noted examples of good care abroad, such as Green House homes in the US and dementia villages in the Netherlands.

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Appendix 2: Roundtable Discussions and Participants

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Appendix 2: Roundtable Discussions and Participants

Younger People in Residential Aged Care

22 November 2018 Quay West Suites 26 Southgate Ave Southbank VIC 3006

Commissioner Attending Ms Lynelle Briggs AO

Attendee Attendee’s Role

Mr Alan Blackwood Policy and Innovation Manager, Young People in Nursing Homes – National Alliance

Mr Luke Bo’sher Chief Executive Officer, Summer Foundation

Ms Sarah Krause Connect Coordinator, Youngcare

Dr Bronwyn Morkham National Director, Young People in Nursing Homes – National Alliance

Dr George Taleporos Policy Manager, Summer Foundation

Commonwealth Agencies

27 November 2018 International Visualisation Centre 19 Young Street Adelaide SA 5000

Commissioner Attending Ms Lynelle Briggs AO

Attendee Attendee’s Role

Ms Gayle Anderson First Assistant Secretary, Client Engagement and Support Services Division, Department of Veterans’ Affairs

Ms Christina Bolger Executive Director, Regulatory Policy and Performance, Australian Aged Care Quality Agency

Ms Pam Christie Executive Director, Industry Engagement and Communication, Australian Aged Care Quality Agency

Ms Helen Grinbergs Acting First Assistant Secretary, Aged Care Royal Commission Taskforce, Department of Health

Ms Sarah Kelly Office of the Aged Care Complaints Commissioner

Ms Rae Lamb Aged Care Complaints Commissioner

Dr Margot McCarthy Deputy Secretary, Population Health, Sport and Aged Care Quality, Department of Health

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Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Mr Nick Ryan Chief Executive Officer, Australian Aged Care Quality Agency

Ms Samantha Taylor PSM Registrar, National Disability Insurance Scheme Quality and Safeguards Commission

Ms Catherine Walsh Executive Director, Client Programs, Client Engagement and Support Services Division, Department of Veterans’ Affairs

Mr Andrew Whitecross Group Manager, National Disability Insurance Scheme Market Reform, Department of Social Services

Aged Care Statisticians

27 November 2018 International Visualisation Centre 19 Young Street Adelaide SA 5000

Commissioner Attending Ms Lynelle Briggs AO

Attendee Attendee’s Role

Ms Justine Boland Program Manager, Health and Disability Branch, Australian Bureau of Statistics

Mr Mark Cooper-Stanbury Head, Disability and Ageing Unit, Australian Institute of Health and Welfare

Ms Louise York Senior Executive, Community Services Group, Australian Institute of Health and Welfare

Consumer Representatives

27 November 2018 International Visualisation Centre 19 Young Street Adelaide SA 5000

Commissioner Attending Ms Lynelle Briggs AO

Attendee Attendee’s Role

Ms Linda Bateman Manager, Aged and Health Support, Returned and Services League Victoria

Ms Sue Elderton National Policy Manager, Carers Australia

Mr Bob Ellis National Vice President, Vietnam Veterans’ Federation of Australia

Mr Ian Henschke Chief Advocate, National Seniors Australia

Mr Tony Lawson Chair, Consumers Health Forum of Australia

Ms Maree McCabe Chief Executive Officer, Dementia Australia

Mr David Panter Board Member, Australian Council of Social Services

Mr Mal Thiele National Vice President, Vietnam Veterans’ Federation of Australia

Mr Ian Yates AM Chief Executive Officer, COTA Australia

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Appendix 2 Roundtable Discussions and Participants

Home Care

27 February 2019 Adina Apartment Hotel Sydney Town Hall 511 Kent Street Sydney NSW 2000

Commissioners Attending Hon Richard Tracey AM RFD QC, Ms Lynelle Briggs AO

Attendee Attendee’s Role

Ms Fiona Duncan National Operations Manager, Aged Care Management Australia

Prof Michael Fine Honorary Professor, Department of Sociology, Macquarie University, New South Wales

Ms Claire Hargreaves Manager, Social Policy, Municipal Association of Victoria

Ms Ronda Held Chief Executive Officer, Council on the Ageing Victoria

Dr Anna Howe Consultant Gerontologist (retired)

Ms Mary Karras Chief Executive Officer, Ethnic Communities Council of New South Wales

Ms Esther Kerr-Smith Group Executive of Finance Australia, Australian Unity

Mr Paul Sadler Chief Executive Officer, Presbyterian Aged Care New South Wales and Australian Capital Territory

Mr David Salisbury General Manager, Consumer and Small Business Strategies, Australian Competition and Consumer Commission

Ms Pat Sparrow Chief Executive Officer, Aged and Community Services Australia

Prof Hal Swerissen Visiting Fellow, Grattan Institute, Victoria

Ms Sue Thompson Chief Executive Officer, McLean Care, New South Wales

Dementia

4 March 2019 Collins Street Tower

Level 3

480 Collins Street

Melbourne VIC 3000

Commissioners Attending Hon Richard Tracey AM RFD QC, Ms Lynelle Briggs AO

Attendee Attendee’s Role

Prof Henry Brodaty Head, Memory Disorders Clinic, Prince of Wales Hospital, Sydney; Co-Director of Centre for Healthy Brain Ageing, New South Wales

Prof Joseph Ibrahim Head, Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash University, Victoria

Dr Stephen Judd Chief Executive Officer, HammondCare, New South Wales

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Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Ms Jennifer Lawrence Chief Executive Officer, Brightwater Care Group, Western Australia

Ms Maree McCabe Chief Executive Officer, Dementia Australia

Mr James Nelson Carer and dementia advocate

Ms Lucy O’Flaherty Chief Executive Officer, Glenview Community Services, Tasmania

Ms Kate Swaffer Chair and Chief Executive Officer, Dementia Alliance International

Prof James Vickers Director, Wicking Dementia Research and Education Centre, University of Tasmania, Tasmania

Commonwealth Agencies

29 April 2019 Realm Hotel

18 National Circuit Barton ACT 2600

Commissioners Attending Hon Richard Tracey AM RFD QC, Ms Lynelle Briggs AO

Attendee Attendee’s Role

Ms Janet Anderson PSM Commissioner, Aged Care Quality and Safety Commission

Ms Glenys Beauchamp PSM Secretary, Department of Health

Ms Pam Christie Executive Director, Industry Engagement and Communication, Aged Care Quality and Safety Commission

Dr Margot McCarthy Deputy Secretary, Department of Health

Mr Nigel Murray Assistant Secretary, Funding Policy and Prudential Branch, Residential and Flexible Aged Care Division, Department of Health

Dr Lisa Studdert Deputy Secretary, Department of Health

Ms Ann Wunsch Executive Director, Quality Assessment and Monitoring Operations, Aged Care Quality and Safety Commission

Culturally and Linguistically Diverse Communities

30 April 2019 Sir Stamford at Circular Quay

93 Macquarie Street Sydney NSW 3000

Commissioner Attending Ms Lynelle Briggs AO

Attendee Attendee’s Role

Dr Bianca Brijnath Adjunct Associate Professor, National Ageing Research Institute, Victoria

Ms Ada Cheng Chief Executive Officer, Australian Nursing Home Foundation, New South Wales

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Appendix 2 Roundtable Discussions and Participants

Dr Jonathan Crichton Senior Lecturer in Applied Linguistics, University of South Australia, South Australia

Ms Anna Maria Harrison Chief Executive Officer, Umbrella Multicultural Community Care Services, Western Australia

Ms Danijela Hlis Dementia and Cultural and Linguistically Diverse Advocate, Tasmania

Ms Penni Michael General Manager Business Development, MiCare, Victoria Dr Lillian Mwanri Public Health Physician; Associate Professor, Discipline of Public Health, Flinders University, South Australia

Ms Mary Patetsos Chairperson, Federation of Ethnic Communities’ Council of Australia Ms Assunta Polito Home Care Coordinator, CORE Community Services, New South Wales

Ms Leyda Suttor Village Manager, Scalabrini Village, Drummoyne, New South Wales

Lesbian, Gay, Bisexual, Transgender and Intersex

30 April 2019 Sir Stamford at Circular Quay

93 Macquarie Street Sydney NSW 3000

Commissioner Attending Ms Lynelle Briggs AO

Attendee Attendee’s Role

Ms Brenda Appleton Chair, Transgender Victoria and Co-Chair, Lesbian, Gay, Bisexual, Transgender and Intersex Taskforce, Victoria

Dr Catherine Barrett Director, Celebrate Ageing, Victoria Ms Samantha Edmonds National Project Manager, Silver Rainbow, National LGBTI Health Alliance

Mr Corey Irlam Director, Advocacy and Government Relations, Council on the Ageing Australia

Ms Samantha Jewell Executive Manager, Lifeview Residential Care, Victoria

Ms Robyn Lierton Diversity Manager, ECH Inc, South Australia Dr Anthony Lyons Associate Professor, Australian Research Centre on Sex, Health and Society, La Trobe University, Victoria

Ms Karen Price Deputy Chief Executive Officer, ACON, New South Wales

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Workforce

2 May 2019 Sir Stamford at Circular Quay

93 Macquarie Street Sydney NSW 3000

Commissioner Attending Ms Lynelle Briggs AO

Attendee Attendee’s Role

Ms Annie Butler National Secretary, Australian Nursing & Midwifery Federation

Ms Carolyn Cooper Chief Executive Officer, Aged Care Team, BUPA Australia Ms Leanne Cover Chief Executive Officer, Canberra Institute of Technology, Australian Capital Territory

Ms Judy Gregurke National Manager, Aged Care Reform Council, Council on the Ageing Australia

Mr Gerard Hayes National Secretary and Branch Secretary, Health Services Union, New South Wales, Australian Capital Territory and Queensland

Ms Natalie James Workplace Relations Advisor, Deloittes Mr Darren Mathewson Executive Director, Strategy and Policy, Aged & Community Services Australia

Prof Kostas Mavromaras Professor of Economics, University of Adelaide, South Australia Ms Maureen McCarty Director, Workforce Data and Analysis and Planning, Health Workforce Division, Department of Health, Australian Capital Territory

Ms Helen Miller Senior Manager, Aged and Community Services, LiveBetter, New South Wales

Mr Stephen Muggleton Group Chief Executive Officer, Bolton Clarke; Board Director, Leading Age Services Australia

Prof John Pollaers OAM Chancellor, Swinburne University, Victoria Ms Carolyn Smith Branch Secretary, United Voice, Western Australian Branch

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Appendix 2 Roundtable Discussions and Participants

Aboriginal and Torres Strait Islanders

28 May 2019 Hilton Adelaide

233 Victoria Square Adelaide SA 5000

Commissioners Attending Hon Richard Tracey AM RFD QC, Ms Lynelle Briggs AO

Attendee Attendee’s Role

Mr Graham Aitken Chief Executive Officer, Aboriginal Community Care, South Australia

Ms Wendy Ashwin Aboriginal Health Co-ordinator, Windsor Park Aged Care Home, Hall and Prior, Western Australia

Ms Venessa Curnow Executive Director, Aboriginal and Torres Strait Islander Health, Torres and Cape Hospital Health Service, Queensland

Ms Rachel Dunn Chief Executive Officer, Karadi Aboriginal Corporation, Tasmania Dr Emma Fitzsimmons General Practitioner, Danila Dilba Health Service, Northern Territory

Mr Matthew Moore General Manager, Aged and Disability Services, Institute for Urban Indigenous Health, Queensland.

Mr Gary Morris OAM Chief Executive Officer and Co-Founder, Booroongen Djugun, New South Wales

Ms Noeleen Tunny Acting Director Policy and Advocacy, Victorian Aboriginal Community Controlled Health Organisations

Ms Patricia Turner AM Chief Executive Officer, National Aboriginal Community Controlled Health Organisations

Commonwealth Agencies: Younger People in Residential Aged Care and Carers

1 July 2019 Rydges Capital Hill Hotel

17 Canberra Ave Forrest ACT 2603

Commissioners Attending Hon Richard Tracey AM RFD QC, Ms Lynelle Briggs AO

Attendee Attendee’s Role

Ms Gayle Anderson First Assistant Secretary, Client Engagement and Support Services, Department of Veterans’ Affairs

Ms Glenys Beauchamp PSM Secretary, Department of Health

Mr Peter Broadhead Acting Group Manager, National Disability Insurance Scheme, Transition Oversight, Department of Social Services

Ms Fiona Buffinton First Assistant Secretary, In Home Aged Care Division, Department of Health

Ms Kathryn Campbell AO Secretary, Department of Social Services CSC

38

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Mr Mark Cormack Deputy Secretary, Policy and Programs, Department of Veterans’ Affairs

Ms Elizabeth Cosson AM, Secretary, Department of Veterans’ Affairs CSC

Mr Michael Francis Deputy Chief Executive Officer, Participants and Planning Experience, National Disability Insurance Agency

Ms Trish Garrett Acting First Assistant Secretary, Cancer, Hearing and Support Division, Department of Health

Ms Helen Grinbergs Acting First Assistant Secretary, Aged Care Royal Commission Taskforce, Department of Health

Mr David Hallinan Deputy Secretary, Ageing and Aged Care, Department of Health

Ms Sarah Johnson Scheme Actuary, National Disability Insurance Agency Mr Michael Lye Deputy Secretary, Disability and Carers, Department of Social Services

Ms Emma-Kate McGuirk Branch Manager, Carer and Disability Payments Branch, Department of Social Services

Mr Scott McNaughton Deputy Chief Executive Officer, Government Communications and Stakeholder Engagement Group, National Disability Insurance Agency

Mr Nigel Murray Assistant Secretary, Funding Policy and Prudential Branch, Department of Health

Ms Vicki Rundle Acting Chief Executive Officer, National Disability Insurance Agency

Mr George Sotiropoulos Group Manager, Disability, Employment and Carers, Department of Social Services

Dr Lisa Studdert Deputy Secretary, Population, Health, Sport and Aged Care Royal Commission Taskforce, Department of Health

Mr Andrew Whitecross Group Manager, National Disability Insurance Scheme, Market Reform Group, Department of Social Services

39

Appendix 3: Witnesses

41

Appendix 3: Witnesses

Adelaide Hearing 1

Witness

Exhibit Date Number Tendered Title

Oral Evidence Given

1. Barbara Spriggs 1-1 11-Feb-19 Statement of

Barbara Elizabeth Spriggs 11-Feb-19

2. Clive Spriggs 1-2 11-Feb-19 Statement of Clive Robert

Spriggs

11-Feb-19

4. Prof John

McCallum

1-4 11-Feb-19 Statement of Professor John McCallum 11-Feb-19

6. Louise York 1-7 12-Feb-19 Statement of Louise York 12-Feb-19

8. Craig Gear 1-8 12-Feb-19 Statement of Craig Gear 12-Feb-19

10. Susan Elderton 1-11 12-Feb-19 Statement of Sue Elderton 12-Feb-19

12. Prof Deborah Parker 1-15 13-Feb-19 Statement of Deborah Parker 13-Feb-19

14. Glenys Beauchamp PSM 1-23 18-Feb-19 Statement of Glenys Anne Beauchamp

18-Feb-19

1-39 18-Feb-19 Corrigendum to the statement of Janet Mary Anderson

17. Maree McCabe 1-44 19-Feb-19 Statement of Maree McCabe 31 January 2019 19-Feb-19

18. Patricia Sparrow 1-45 19-Feb-19 Statement of Patricia Lee 19-Feb-19 Sparrow

19. Sean Rooney 1-46 19-Feb-19 Statement of

Sean Thomas Rooney

19-Feb-19

1-47 Second statement of

Sean Thomas Rooney

3. Ian Yates AM 1-3 11-Feb-19 Statement of Ian Garth Yates 11-Feb-19

5. Justine Boland 1-6 12-Feb-19 Statement of 12-Feb-19

Justine Louise Boland

7. Mark Cooper- n/a n/a 12-Feb-19

Stanbury

9. Paul Versteege 1-9 12-Feb-19 Statement of Paul Versteege 12-Feb-19

11. Assoc Prof 1-14 13-Feb-19 Statement of Edward Strivens 13-Feb-19

Edward Strivens

13. Annie Butler 1-16 13-Feb-19 Statement of Annie Butler 13-Feb-19

15. Janet Anderson 1-38 18-Feb-19 Statement of Janet Mary 18-Feb-19

PSM Anderson

16. Dr Harry 1-40 18-Feb-19 Statement of Dr Harry Nespolon 18-Feb-19

Nespolon

42

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Date Number Tendered

Oral Evidence Given

Witness Title

20. Nicolas Mersiades

1-50 19-Feb-19 Statement of Nicolas George Mersiades 19-Feb-19

21. Claerwen Little 1-51 20-Feb-19 Statement of Claerwen Eleanor Little 20-Feb-19

22. Melissa Coad 1-52 20-Feb-19 Statement of Melissa Coad 20-Feb-19

23. Matthew Richter 1-54 20-Feb-19 Statement of Matthew Graham Richter 20-Feb-19

1-55 20 Feb 19 Supplementary statement of Mr Richter

24. Dr Anthony Bartone 1-56 20-Feb-19 20-Feb-19

Statement of Dr Anthony Bartone

20-Feb-19

1-57

Additional statement of Dr Anthony Bartone

25. Gerard Hayes 1-60 21-Feb-19 Statement of Gerard John Hayes 21-Feb-19

26. Kaye Warrener 1-61 21-Feb-19 Statement of Kaye Frances Warrener 21-Feb-19

27. Margaret Harker 1-62 21-Feb-19 Statement of Margaret Jane Harker 21-Feb-19

28. Barrie Anderson 1-63 21-Feb-19 Statement of Barrie Anderson 21-Feb-19

Adelaide Hearing 2

Witness

Exhibit Number Date Tendered

Title

Oral Evidence Given

29. Lynda Henderson 2-1 18-Mar-19 Statement of Lynda Henderson 18-Mar-19 2-3 18-Mar-19 Video of Lynda Henderson

and Veda Meneghetti

31. BE 2-9 18-Mar-19 Statement of BE 18-Mar-19

33. Josef Rack 2-15 19-Mar-19 Statement of Josef Rack 19-Mar-19

35. David Moran 2-23 19-Mar-19 Statement Signed by David Moran and Caroline Ford on behalf of Southern Cross Care

19-Mar-19

36. Clare Hargreaves 2-25 19-Mar-19 Statement of 19-Mar-19

Clare Lynette Hargreaves

30. Raelene Ellis 2-4 18-Mar-19 Statement of Raelene Ann Ellis 18-Mar-19

32. Paul Sadler 2-12 18-Mar-19 Statement of 18-Mar-19

Paul Michael Sadler

34. Caroline Ford 2-23 19-Mar-19 Statement Signed by David 19-Mar-19

Moran and Caroline Ford on behalf of Southern Cross Care

43

Appendix 3 Witnesses

Exhibit Number Date Tendered

Oral Evidence Given

Witness Title

37. Sally Warren 2-26 19-Mar-19 Statement of

Sally Francis Warren

19-Mar-19

39. Anna Hansen 2-28 19-Mar-19 Statement of

Anna Gabrielle Hansen 19-Mar-19

41. Gregory Holmes N/A 19-Mar-19 N/A 19-Mar-19

43. Marie Dowling 2-34 20-Mar-19 Statement of Marie Dowling 20-Mar-19

45. Mary Patetsos 2-37 20-Mar-19 Statement of Mary Patetsos 20-Mar-19

47. Graeme Barden 2-78 21-Mar-19 Statement of Graeme Barden 21-Mar-19

49. Dr Lisa Studdert N/A 21-Mar-19 N/A 21-Mar-19

51. Prof Hjalmar Swerissen 2-86 21-Mar-19 Statement of Professor Hjalmar Swerissen

21-Mar-19

52. Fiona Buffinton 2-89 22-Mar-19 Statement of Fiona Kathryn 22-Mar-19 Buffinton dated 11 March 2019

Sydney Hearing

Witness

Exhibit Number Date Tendered

Title

Oral Evidence Given

53. Merle Mitchell AM 3-1 6-May-19 Statement of Merle Valma Mitchell AM 6-May-19

54. Darryl Melchhart 3-3 6-May-19 Statement of

Darryl Hilda Melchhart

6-May-19

56. Eresha Dassanayake 3-6 6-May-19 Statement of

Eresha Dilum Dassanayake 6-May-19

58. Michelle McCulla 3-9 7-May-19 Statement of

Michelle Lauren McCulla 7-May-19

38. Heather Jackson 2-27 19-Mar-19 Statement of 19-Mar-19

Heather Virginia Jackson

40. Rosemary Dale 2-29 19-Mar-19 Statement of 19-Mar-19

Rosemary Anne Dale

42. BC 2-33 20-Mar-19 Statement of BC 20-Mar-19

44. BA 2-36 20-Mar-19 Statement of BA 20-Mar-19

46. Ruth Harris 2-76 21-Mar-19 Statement of Ruth Harris 21-Mar-19

48. Rita Kersnovske 2-80 21-Mar-19 Statement of Rita May 21-Mar-19

Kersnovske

50. Anthony Speed N/A 21-Mar-19 N/A 21-Mar-19

55. George Akl 3-4 6-May-19 Statement of George Akl 6-May-19

57. Lillian Reeves 3-8 6-May-19 Statement of Lillian Reeves 6-May-19

59. Natalie Smith 3-10 7-May-19 Statement of 7-May-19

Natalie Sonya Smith

44

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Date Number Tendered

Oral Evidence Given

Witness Title

3-11 7-May-19 Supplementary statement

of Natalie Sonya Smith

61. Dr Miles Burkitt 3-13 7-May-19 Statement of Dr Miles Burkitt 7-May-19

63. Kee Lau 3-15 7-May-19 Statement of Kee Ling Lau 7-May-19

65. DL 3-21 8-May-19 Statement of DL 8-May-19

3-23 8-May-19 Supplementary statement of

Richard Farmilo

67. Cheryl Lee 3-26 8-May-19 Statement of Cheryl Lee 8-May-19

69. Kathryn Nobes 3-28 8-May-19 Statement of Kathryn Jill Nobes 8-May-19

71. Marian Anderson 3-33 8-May-19 Statement of Marian Anderson 8-May-19

73. DJ 3-36 13-May-19 Statement of DJ 13-May-19

75. Glenn Rees 3-40 13-May-19 Statement of Glenn Eric Rees 13-May-19

77. Tamar Krebs 3-45 14-May-19 Statement of Tamar Chayen Krebs 14-May-19

79. Jennifer Lawrence

3-46 14-May-19 Statement of Jennifer Lawrence 14-May-19

81. Prof Constance Pond 3-48 14-May-19 Statement of Professor Constance Dimity Pond

14-May-19

3-50 14-May-19 Supplementary Statement

of Professor Elizabeth Ruby Anne Beattie

83. Dr Peter Foltyn 3-51 14-May-19 Statement of Dr Peter Foltyn 14-May-19

60. Jayanthi Kannan 3-12 7-May-19 Statement of Jayanthi Kannan 7-May-19

62. Dr Kenneth Wong 3-14 7-May-19 Statement of Dr Kenneth Wong 7-May-19

64. DM 3-20 8-May-19 Statement of DM 8-May-19

66. Richard Farmilo 3-22 8-May-19 Statement of Richard Farmilo 8-May-19

3-83 17-May-19 Second supplementary statement of Richard Farmilo

68. Dr Margaret 3-27 8-May-19 Statement of 8-May-19

Ginger Dr Margaret Ann Ginger

70. DF 3-32 8-May-19 Statement of DF 8-May-19

72. DI 3-35 13-May-19 Statement of DI 13-May-19

74. Maureen Berry 3-38 13-May-19 Statement of Maureen 13-May-19

Mary Berry

76. Amy Tinley 3-44 13-May-19 Statement of Amy Tinley 13-May-19

78. Jonathan N/A N/A N/A 14-May-19

Gavshon

80. Lucille O’Flaherty 3-47 14-May-19 Statement of Lucille Claire 14-May-19 O’Flaherty

82. Prof Elizabeth 3-49 14-May-19 Statement of Professor 14-May-19

Beattie Elizabeth Ruby Anne Beattie

45

Appendix 3 Witnesses

Exhibit Number Date Tendered

Oral Evidence Given

Witness Title

84. Assoc Prof Lynette Goldberg 3-52 14-May-19 Statement of Associate Professor Lynette

Ruth Goldberg

14-May-19

86. Elizabeth 3-57 15-May-19 Statement of Elizabeth 15-May-19

88. Susan Walton 3-59 15-May-19 Statement of 15-May-19

Susan Marie Walton

90. Dr Juanita Breen (formerly Westbury)

3-61 15-May-19 Statement of Dr Juanita Westbury 15-May-19

92. Prof Joseph Ibrahim 3-70 16-May-19 Statement of Professor Joseph Elias Ibrahim

16-May-19

94. Amy Laffan 3-78 16-May-19 Statement of

Amy Elizabeth Laffan

16-May-19

96. Prof Henry Brodaty AO 3-80 17-May-19 Statement of Professor Henry Brodaty AO

17-May-19

98. Kate Swaffer 3-84 17-May-19 Statement of Kate Swaffer 17-May-19

Broome Hearing

Witness

Exhibit Number Date Tendered

Title

Oral Evidence Given

99. Madeleine Jadai N/A N/A N/A 17-Jun-19

100. Faye Dean 4-2 17-Jun-19 Statement of Ms Faye Dean 17-Jun-19

102. Yvonne Grosser 4-3 17-Jun-19 Statement of Yvonne Grosser 17-Jun-19

104. Tamra Bridges 4-5 17-Jun-19 Statement of

Tamra Jade Bridges

17-Jun-19

85. Prof Brendan 3-55 14-May-19 Statement of Professor 14-May-19

Murphy Brendan Francis Murphy

87. Margaret Bain 3-58 15-May-19 Statement of 15-May-19

Margaret Ellen Bain

89. Suzanne Wilson 3-60 15-May-19 Statement of 15-May-19

Suzanne Wendy Wilson

91. Assoc Prof 3-68 15-May-19 Statement of Associate 15-May-19

Stephen Professor Stephen Macfarlane

Macfarlane

93. Christina Bolger 3-75 16-May-19 Statement of 16-May-19

Christina Mary Bolger

95. Josephine Mond 3-79 16-May-19 Statement of Josephine Mond 16-May-19

97. Trevor Crosby 3-82 17-May-19 Statement of 17-May-19

Trevor Douglas Crosby

101. Ryan Hammond N/A N/A N/A 17-Jun-19

103. Craig Barke 4-4 17-Jun-19 Statement of Craig Robin Barke 17-Jun-19

46

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Witness

Exhibit Number Date Tendered

Title

Oral Evidence Given

105. Prof Leon Flicker AO 4-6 17-Jun-19 Statement of Professor Leon Flicker

17-Jun-19

18-Jun-19

107. Graham Aitken 4-8 18-Jun-19 Statement of 18-Jun-19

Graham John Aitken

108. Ruth Crawford 4-9 18-Jun-19 Statement of Ruth Ann Crawford 18-Jun-19

109. Belinda Robinson 4-10 18-Jun-19 Statement of 18-Jun-19

Belinda Jayne Robinson

110. Rejane Le Grange 4-11 18-Jun-19 Statement of 18-Jun-19

Rejane Antoinette Le Grange

111. Dr Michael 4-12 18-Jun-19 Statement of 18-Jun-19

Preece Dr Michael Stephen Preece

112. Dr Kate Fox 4-13 19-Jun-19 Statement of 19-Jun-19

Dr Kate Suzanne Fox

4-14 Second statement of

Dr Kate Suzanne Fox

113. Roslyn Malay 4-15 19-Jun-19 Statement of Roslyn Malay 19-Jun-19

114. Venessa Curnow 4-16 19-Jun-19 Statement of 19-Jun-19

Venessa Michelle Curnow

Perth Hearing

Witness

Exhibit Number Date Tendered

Title

Oral Evidence Given

115. Noleen Hausler 5-9 24-Jun-19 Statement of Noleen Joy Hausler 24-Jun-19

116. Rachel Musico 5-10 24-Jun-19 Statement of Rachel Ann Musico 24-Jun-19

118. Julie Reed 5-12 24-Jun-19 Statement of Julie Reed 24-Jun-19

25-Jun-19

120. Jason Burton 5-14 25-Jun-19 Statement of Jason Burton 25-Jun-19

122. Chris Mamarelis N/A N/A N/A 25-Jun-19

124. Kevin Chester 5-17 25-Jun-19 Statement of Kevin Charles Chester 25-Jun-19

125. Kate Rice 5-18 25-Jun-19 Statement of Kate Rice 25-Jun-19

117. Diane Jones 5-11 24-Jun-19 Statement of Diane Jones 24-Jun-19

119. Mark Sudholz 5-13 25-Jun-19 Statement of 25-Jun-19

Mark Andrew Sudholz

121. EA 5-15 25-Jun-19 Statement of EA 25-Jun-19

123. Carolyn Jubb 5-16 25-Jun-19 Statement of Carolyn Gai Jubb 25-Jun-19

106. Dr Martin Laverty 4-7 18-Jun-19 Statement of Martin John Laverty

47

Appendix 3 Witnesses

Exhibit Number Date Tendered

Oral Evidence Given

Witness Title

126. Bryan Lipmann AM 5-19 25-Jun-19 Statement of Bryan David Lipmann

25-Jun-19

127. Anthony 5-1 30-May-19 Statement of 25-Jun-19

O’Donnell

5-20 25-Jun-19

Anthony Patrick O’Donnell Video: Examination of Anthony Patrick O’Donnell

128. Stuart Woodley 5-21 26-Jun-19 Statement of Stuart Woodley 26-Jun-19

129. Gaye Whitford 5-22 26-Jun-19 Statement of 26-Jun-19

Gaye Margaret Whitford

130. Emma-Kaitlin Murphy 5-23 26-Jun-19 Statement of Emma-Kaitlin Murphy

26-Jun-19

131. Anna Urwin 5-24 26-Jun-19 Statement of 26-Jun-19

Anna Christine Urwin

132. Patti Houston 5-25 26-Jun-19 Statement of

Patti Annie Houston

26-Jun-19

133. Hon Dr Kay 5-26 26-Jun-19 Statement of The Hon Dr Kay 26-Jun-19

Patterson AO Christine Lesley Patterson AO

134. Dale Fisher 5-27 26-Jun-19 Statement of Dale Allyson Fisher 26-Jun-19

135. Matthew Moore 5-28 26-Jun-19 Statement of 26-Jun-19

Matthew John Moore

136. Dr Mike Rungie 5-29 26-Jun-19 Statement of John Michael Rungie 26-Jun-19

137. Dr Craig Sinclair 5-30 26-Jun-19 Statement of 26-Jun-19

Craig Bowman Sinclair

138. Shannon Ruddock

5-32 27-Jun-19 Statement of Shannon Maree Ruddock 27-Jun-19

139. Joshua Cohen 5-33 27-Jun-19 Statement of 27-Jun-19

Joshua Bedford Cohen

5-34 27-Jun-19 Statement of Joshua Bedford Cohen

140. John Leong 5-35 27-Jun-19 Second Statement of 27-Jun-19

John Leong

5-36 27-Jun-19 Statement of John Leong

141. Prof Jennifer 5-37 27-Jun-19 Statement of 27-Jun-19

Tieman Jennifer Joy Tieman

142. Dr Jane Fischer 5-38 27-Jun-19 Statement of Jane Fischer 27-Jun-19

143. Dr Elizabeth 5-39 27-Jun-19 Statement of 27-Jun-19

Reymond Elizabeth Nancy Reymond

144. Dr Lisa Trigg 5-40 28-Jun-19 Statement of Lisa Jane Trigg 28-Jun-19

48

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Darwin and Cairns Hearing

Witness

Exhibit Number Date Tendered

Title

Oral Evidence Given

145. Dr Meredith Hansen-Knarhoi 6-2 08-Jul-19 Statement of

Dr Meredith Hansen-Knarhoi 08-Jul-19

146. Mildred 6-2 08-Jul-19 Video statement of 08-Jul-19

Numamurdirdi Mildred Numamurdirdi

147. Sarah Brown 6-3 08-Jul-19 Statement of 08-Jul-19

Sarah Louise Brown

148. Kim McRae 6-4 08-Jul-19 Statement of Kim Maree McRae 08-Jul-19 149. Donna Chee 6-5 08-Jul-19 Statement of Ms Donna Ah Chee 08-Jul-19 concurred in by Dr Boffa

150. Dr John Boffa 6-5 08-Jul-19 Statement of Ms Donna Ah Chee 08-Jul-19 concurred in by Dr Boffa

151. Olga Havnen 6-6 08-Jul-19 Statement of Olga Havnen 08-Jul-19

concurred in by Dr Giles

152. Dr Sarah Giles 6-6 08-Jul-19 Statement of Olga Havnen concurred in by Dr Giles 08-Jul-19

154. Lyndall Fowler 6-9 09-Jul-19 Statement of Lyndall Helen Fowler as amended 09-Jul-19

6-10 09-Jul-19 Statement of Lyndall Helen Fowler to Royal Commission Into Safety and Quality of Aged Care

155. Kristy Taylor 6-11 09-Jul-19 Statement of Kristy Lee Taylor 09-Jul-19 as amended

156. Sophoronia 6-12 09-Jul-19 Statement of 09-Jul-19

Briguglio Sophoronia Briguglio

157. Dr Robert Bird 6-14 10-Jul-19 Statement of Dr Robert Keith Bird dated 27 June 2019 09-Jul-19

Supplementary Statement of Dr

Robert Bird dated 22 July 2019

159. Dr Eric Tay 6-16 10-Jul-19 Statement of Eric Tiong Yew Tay 10-Jul-19

160. Paul Cohen 6-17 10-Jul-19 Statement of Paul Stephen 10-Jul-19

Cohen as amended

6-18 10-Jul-19 Supplementary Statement of

Paul Stephen Cohen

10-Jul-19

162. Lisa Backhouse 6-20 11-Jul-19 Statement of Lisa Maree Backhouse 11-Jul-19

153. Michelle McKay 6-7 08-Jul-19 Statement of Michelle McKay 08-Jul-19

158. Anamaria Ng 6-15 10-Jul-19 Statement of Anamaria Ng 10-Jul-19

161. Donato Smarrelli 6-19 10-Jul-19 Statement of Donato Smarrelli 10-Jul-19

49

Appendix 3 Witnesses

Witness

Exhibit Number Date Tendered

Title

Oral Evidence Given

163. Assoc Prof Peter Gonski 6-21 11-Jul-19 Statement of Associate Professor Peter Neil Gonski

11-Jul-19

164. Prof Johanna Westbrook 6-22 11-Jul-19 Statement of

Johanna Irene Mary Westbrook 11-Jul-19

6-23 11-Jul-19 Supplementary statement of 11-Jul-19 Johanna Irene Mary Westbrook

165. Prof Michael Murray AM 6-24 11-Jul-19 Statement of Michael John Murray as amended

11-Jul-19

166. Dr Joan 6-25 11-Jul-19 First Statement of 11-Jul-19

Ostanszkiewicz Joan Ostaszkiewicz

6-26 11-Jul-19 Second Statement of Joan Ostaszkiewicz 11-Jul-19

6-27 11-Jul-19 Corrigendum of 11-Jul-19

Joan Ostaszkiewicz

167. Catherine Sharp 6-28 11-Jul-19 Statement of Catherine Anne Sharp 11-Jul-19

168. Sally Hopkins 6-29 11-Jul-19 Statement of 11-Jul-19

Sally Jeanne Hopkins

169. Prof Geoffrey Sussman 6-30 11-Jul-19 Statement of Professor Geoffrey Sussman and Ms Hayley Ryan

11-Jul-19

170. Hayley Ryan 6-30 11-Jul-19 Statement of Professor Geoffrey 11-Jul-19 Sussman and Ms Hayley Ryan

171. Jo-Ann Lovegrove 6-31 12-Jul-19 Statement of Jo-Ann Mayse Lovegrove 12-Jul-19

172. Dr Janet Sluggett 6-32 12-Jul-19 Statement of 12-Jul-19

Janet Kathleen Sluggett

173. Catherine Maloney

6-33 12-Jul-19 Statement of

Catherine Mary Maloney 12-Jul-19

174. Sharai Johnson 6-34 12-Jul-19 Statement of Larrakia Nation 12-Jul-19 Aboriginal Corporation

175. Michelle McCall 6-34 12-Jul-19 Statement of Larrakia Nation Aboriginal Corporation 12-Jul-19

176. Anna Morgan 6-34 12-Jul-19 Statement of Larrakia Nation 12-Jul-19 Aboriginal Corporation

177. Johanna Aalberts- Henderson 6-36 15-Jul-19 Statement of Johanna Aalberts-Henderson

15-Jul-19

178. Robert Van 6-37 15-Jul-19 Statement of R 15-Jul-19

Duuren obert Van Duuren

6-38 15-Jul-19 Supplementary Statement of Robert Van Duuren

50

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Witness

Exhibit Number Date Tendered

Title

Oral Evidence Given

179. Jan Rice 6-39 15-Jul-19 Statement of Jan Rice 15-Jul-19

6-40 15-Jul-19 Additional statement of Jan Rice 180. Petronella 6-41 15-Jul-19 Statement of 15-Jul-19

Neeleman Petronella Dorothea Neeleman

6-42 15-Jul-19 Supplementary statement of Petronella Dorothea Neeleman 15-Jul-19

181. Nicholas Hall 6-43 16-Jul-19 Statement of 16-Jul-19

Nicholas Michael Zane Hall

16-Jul-19

183. Lindy Twyford 6-45 16-Jul-19 Statement of 16-Jul-19

Lindy Maree Twyford

184. Maggie Beer AM 6-46 16-Jul-19 Statement of Maggie Beer 16-Jul-19 185. Dr Sandra Iuliano 6-47 16-Jul-19 Statement of Dr Sandra Iuliano 16-Jul-19

16-Jul-19 Corrigendum to Statement of Dr Sandra Iuliano 186. Robert Hunt 6-48 16-Jul-19 Statement of Robert Hunt 16-Jul-19

and Sharon Lawrence on behalf of the Dietitians Association of Australia

187. Sharon Lawrence 6-48 16-Jul-19 Statement of Robert Hunt and Sharon Lawrence on behalf of the Dietitians Association of Australia

16-Jul-19

189. Dr Frances Batchelor 6-50 16-Jul-19 Statement of

Frances Anne Batchelor 16-Jul-19

191. Lisa Jones 6-52 17-Jul-19 Statement of Lisa Jayne Jones 17-Jul-19

193. FA 6-54 17-Jul-19 Statement of FA 17-Jul-19

195. Angela Raguz 6-56 17-Jul-19 Statement of Angela Raguz 17-Jul-19

197. Dr Jennifer Abbey 6-58 17-Jul-19 Statement of Dr Jennifer Ann Abbey 17-Jul-19

188. Adrienne Lewis 6-49 16-Jul-19 Statement of 16-Jul-19

Adrienne Alexis Lewis

190. Elise Scott 6-51 17-Jul-19 Statement of Elsie Marion Scott 17-Jul-19

192. Natasha 6-53 17-Jul-19 Statement of 17-Jul-19

Chadwick Natasha Jane Chadwick

194. Sandy Green 6-55 17-Jul-19 Statement of Sandy Marie Green 17-Jul-19

196. Dr Drew Dwyer 6-57 17-Jul-19 Statement of Drew Darren Dwyer 17-Jul-19

182. Timothy Deverell 6-44 16-Jul-19 Statement of Timothy John Deverell

51

Appendix 4: Exhibits

53

Appendix 4: Exhibits

1-2 WIT.0026.0001.0001 Statement of Clive Robert Spriggs

WIT.0006.0002.0001 Index to Exhibits to Statement of Mr Yates

COT.9999.2222.0001 Care at Home AG Paper

COT.1111.1111.0002 5 Fixes

COT.9999.2222.0003 Blueprint II

COT.1111.2222.0004 Consumer Choice Project Report

COT.2222.2222.0007 Advisory Service Project Report

COT.9999.2222.0008 Assistive Technology

COT.9999.2222.0011 Blueprint I

COT.9999.2222.0012 2016 Election

COT.9999.2222.0013 Integrated Consumer Supports

COT.1111.1111.0014 Legislated Review Submission

COT.1111.1111.0015 Carnell Patterson Submission

RCD.9999.0001.0122 NACA Submission integrated Care at Home

RCD.9999.0002.0001 Aged Care Sector Committee - Strategic Roadmap for Aged Care

1-4 WIT.0004.0001.0001 Statement of Professor John McCallum

NSA.9999.0002.0001 Summary Table of Member Issues

NSA.9999.0003.0001 You don’t know what you don’t know

NSA.9999.0004.0001 Hope for the best

NSA.9999.0005.0001 Dealing with Diversity

NSA.9999.0006.0001 Consumer Directed Care in Australia

NSA.9999.0007.0001 Respect for Age

UVH.0001.0007.0001 A Matter of Care – Australia’s Aged Care Workforce Strategy

1-5 NSA.9999.0001.0001 Accentuating The Positive

Day 3 – 12 February 2019

Exhibit Number Document Number

Exhibit

1-6 WIT.0001.0001.0001 Statement of Justine Louise Boland CTH.0001.7000.0181 Corporate plan 2018-19

CTH.0001.7000.0217 SDAC Household Questionnaire

CTH.0001.7000.0021 SDAC Residential Care

Adelaide 1

Day 2 – 11 February 2019

Exhibit Number Document Number

Exhibit

1-1 WIT.0025.0001.0001 Statement of Barbara Elizabeth Spriggs

1-3 WIT.0006.0001.0001 Statement of Ian Garth Yates

54

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

CTH.0001.7000.0001 SDAC List of Topics

CTH.0001.7000.0003 Disability Module

CTH.0001.7000.0020 MADIP Overview

CTH.0001.7000.0738 Proportion of older Australians categorised by sex from 1911 to 2016

CTH.0001.7000.0013 Number of older Australians by age group, from 1911 to 2016

CTH.0001.7000.0734 Number of males per 100 females, by age group, from 1911 to 2016

CTH.0001.7000.0735 Proportion of older Australians by State and Territory, 2016 and 2006

CTH.0001.7000.0737 Proportion of older Australians by section of State (Major Urban, Other Urban, Bounded Locality and Rural), 2016

CTH.0001.7000.0018 Region of birth of older Australians, 2016 CTH.0001.7000.0733 Top five languages other than English spoken at home by older Australians, 2016

CTH.0001.7000.0739 Proportion of people with a need for assistance analysed by dwelling type, 2016

CTH.0001.7000.0732 Analysis of the type of household type, with a spouse or partner, with other relatives, group households and lone person) for males and females, 2016

CTH.0001.7000.0736 Income and labour force participation by older Australians 2006 to 2016

CTH.0001.7000.0050 SDAC

CTH.0001.7000.0045 Dementia

CTH.0001.7000.0180 Key statistics

CTH.0001.7500.1014 LY1-1

CTH.0001.7500.0132 LY1-2

CTH.0001.7500.1140 AIHW Aged Care Data Advisory Group Terms of Reference

CTH.0001.7500.1008 Annexure Data Sources

CTH.0001.7500.0054 National Aged Care Data Clearinghouse Data Dictionary – Version 1

CTH.0001.7500.0124 Services and Places in Aged Care

CTH.0001.7500.0006 Explore Services and Places in Aged Care

CTH.0001.7500.0009 Services and Places Infographic 2016/17

CTH.0001.7500.0001 Explore Admissions into Aged Care

CTH.0001.7500.0129 Admissions into aged care infographic 2016/17

CTH.0001.7500.0007 Explore People Using Aged Care

1-7 WIT.0002.0001.0001 Statement of Louise York

CTH.0001.7500.1013 Publication’s Index

CTH.0001.7500.0017 LY1-3

CTH.0001.7500.0122 Cause of Death Patterns

CTH.0001.7500.0111 Admissions into Aged Care

CTH.0001.7500.0011 Admissions into aged care fact sheet 2016/17

CTH.0001.7S00.0002 People Using Aged Care

55

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

CTH.0001.7500.0120 People Using Aged Care Factsheet 2016/17

CTH.0001.7S00.0016 People Using Aged Care Infographic 2016/17

CTH.0001.7500.0010 Explore People’s Care Needs in Aged Care

CTH.0001.7500.0013 People’s Care Needs in Aged Care Factsheet 2016/17

CTH.0001.7500.0113 Explore People Leaving Aged Care

CTH.0001.7500.0115 Spending Factsheet 2016/17

CTH.0001.7500.0004 Government Spending in Aged Care

CTH.0001.7500.0015 Spending Infographic 2016/17

CTH.0001.7500.0114 Explore Pathways in Aged Care

CTH.0001.7500.0130 2018 Indigenous Dashboard

CTH.0001.7500.0143 Employment Dashboard

CTH.0001.7500.0636 Chapter 6 – Australia’s Welfare 2015

CTH.0001.7500.1020 Older Australia at a glance, Demographics of older Australians - Australian Institute of Health and Welfare

CTH.0001.7500.1081 Pathways to Aged Care

CTH.0001.7500.1022 Cause of Death Patterns

CTH.0001.7500.0156 Trends in Falls

CTH.0001.7500.1142 Overview of Aged Care System

OPA.001.001.0001 Craig Gear Director – CGA Consulting

OPA.001.001.0015 2018 Annual Report

OPA.001.001.0063 CG-5

1-10 RCD.9999.0005.0001 Aged Care Regulation in Quality - Activity and Actions

1-11 WIT.0003.0001.0001 Statement of Susan Tracy Elderton

1-12 RCD.9999.0003.0001 Deloitte Access Economics Report: the Economic Value of Informal Care in Australia in 2015

1-13 RCD.9999.0004.0001 AIHW and ABS Graphs

CTH.0001.7500.0003 People’s Care Needs in Aged Care

CTH.0001.7500.0119 People’s Care Needs in Aged Care Infographic 2016/17

CTH.0001.7500.0005 People Leaving Aged Care

CTH.0001.7500.0008 People Leaving Aged Care Infographic 2016/17

CTH.0001.7500.0117 People Leaving Aged Care Factsheet 2016/17

CTH.0001.7500.0053 Explore Government Spending in Aged Care

CTH.0001.7S00.0115 Spending Factsheet 2016/17

CTH.0001.7500.0112 Pathways in Aged Care

CTH.0001.7500.0125 2017 Snapshot Dashboard

CTH.0001.7500.0141 People Dashboard

CTH.0001.7500.0145 AIHW Australia’s Welfare 2017 Chapter 5

CTH.0001.7500.1148 Report – Movement from Hospital to Residential Aged Care

CTH.0001.7500.0620 Hospital Care for Patients Aged 85 and Over

1-8 WIT.0007.0001.0001 Statement of Craig Gear

OPA.001.001.0005 National Aged Care Advocacy Framework

OPA.001.001.0034 CG-4

1-9 WIT.0009.0001.0001 Statement of Mr Versteege

56

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Day 4 – 13 February 2019

Exhibit Number

Document Number

Exhibit

1-13 RCD.9999.0004.0001 AIHW and ABS Graphs

1-14 WIT.0021.0001.0001 Statement of Edward Strivens

ESG.9999.0001.0001 ANZSGM 1 Position Statement 8 Comprehensive Geriatric Assessment and Community Practice

ESG.9999.0002.0001 ANZSGM 2 Position Statement 9 The Provision of Medical Services to Residential Aged Care facilities in Australia

ESG.9999.0003.0001 ANZSGM 3 Position Statement 29 Prescribing in Older People

ESG.9999.0004.0001 ANZSGM 4 Position Statement 21 Pain in Older People

ESG.9999.0005.0001 ANZSGM 5 Position Statement 28 Dementia in Older People

1-15 WIT.0017.0001.0001 Statement of Deborah Parker

1-16 WIT.0020.0001.0001 Statement of Annie Butler

1-17 RCD.9999.0001.0105 Public Health System Nurses’ & Midwifes Award 2018 (NSW)

1-18 RCD.9999.0001.0112 Generic Health NSW Enterprise Agreement 2018

1-19 ANM.0001.0001.0787 Australian Nursing and Midwifery Federation National Aged Care Survey

1-20 ANM.0001.0001.3151 National Aged Care Staffing and Skills Mix Project Report 2016.

1-21 ANM.0001.0001.3308 Financial and Cost Benefit Implications of the Recommendations of the National Aged Care Staffing and Skills Mix Final Report.

Day 5 – 18 February 2019

Exhibit Number

Document Number

Exhibit

1-22 ANM.0001.0001.2102 Ratios Save Lives Supporting Research, May 2018

1-23 WIT.0022.0001.0001 Statement of Glenys Anne Beauchamp

CTH.0001.1000.3997 Department of Health, Home Care Packages Data Report- 2018-19-1st-Qtr

CTH.0001.1000.4519 Aged Care Expenditure

CTH.0001.1000.4676 Quality of Care Principles 2014

CTH.0001.1000.4726 User Rights Principles 2014

CTH.0001.1000.4651 Accountability Principles 2014

CTH.1000.1012.2385 Aged Care Quality Standards.pdf

CTH.1000.0001.2180 Exhibit GAB1-6

CTH.1000.0001.2203 Exhibit GAB1-6

CTH.1000.0001.2293 Exhibit GAB1-6

CTH.0001.1000.4515 List of health programs relevant to aged care and diagram of interaction between health care and aged care

57

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

CTH.0001.1000.0021 Australian Government response to the Senate Community Affairs References Committee Interim Report, June 2018

CTH.0001.1000.4506 Tune Review recommendations - Implementation progress - Feb 2019

CTH.0001.1000.4510 Carnell-Paterson recommendations - Implementation progress - Feb 2019

CTH.100.1038.0872 2016 National Aged Care Workforce Census and Survey – The Age Care Workforce, 2016

1-24 RCD.9999.0011.0734 Budget Paper May 2018, Department of Health

1-25 RCD.9999.0011.1833 Review of National Aged Care Quality Regulatory Processes by Ms Kate Carnell and Professor Ron Paterson, October 2017

1-26 CTH.2000.1000.5400 Australian Aged Care Quality Agency - What Are Consumers Saying About Aged Care?

1-27 RCD.9999.0011.0302 Australian Law Reform Commission, Report 131, Elder Abuse – A National Legal Response, May 2017

1-28 RCD.9999.0011.2033 The Hon, Ken Wyatt MP, Media Release, 17 January 2019

1-29 RCD.9999.0011.2027 Prime Minister, Minister for Health, Minister for Senior Australians and Aged Care Media Release, 17 December 2019

1-30 RCD.9999.0011.2022 The Hon. Greg Hunt MP and the Hon. Ken Wyatt MP, Media Release, 17 December 2018

1-31 RCD.9999.0011.0943 Productivity Commission Inquiry Report entitled Caring for Older Australians, Overview

1-32 RCD.9999.0011.1031 Caring for Older Australians, Productivity Commission Inquiry Report No 53 dated 28 June 2011 - Volume 1

1-33 RCD.9999.0011.1261 Caring for Older Australians, Productivity Commission Inquiry Report No 53 dated 28 June 2011 - Volume 2

1-34 RCD.9999.0011.0120 Aged Care Financing Authority, Sixth Report on the Funding and Financing of the Aged Care Sector dated July 2018

1-35 RCD.9999.0011.0746 Legislated Review of Aged Care 2017

1-36 RCD.9999.0011.2021 Department of Health, Resource Utilisation and Classification Study and Residential Aged Care Funding Reform, Stakeholder Forum Communique dated 19 November 2018

1-37 RCD.9999.0011.0001 Department of Health, 2017-18 Report on the Operation of the Aged Care Act 1997

1-38 WIT.0023.0001.0001 Statement of Janet Mary Anderson

CTH.0001.4000.2132 Complaints Management Flow Chart

CTH.0001.4000.2133 Commission Organisational Chart

CTH.0001.4000.0009 New Aged Care Quality Standards

CTH.0001.4000.1686 Aged Care Quality Standards fact sheet

CTH.0001.4000.1906 Guidance and Resource Document

CTH.0001.4000.2135 Self-Assessment Tool

CTH.0001.4000.2193 Guidance for Self-Assessment

CTH.0001.4000.0003 Charter of Aged Care Rights

58

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

CTH.2000.1000.5400 What are consumers saying about aged care?

CTH.0001.4000.2129 Ensuring Safe, Quality Aged Care

CTH.0001.4000.0243 Let’s Talk about Quality, December 2015

CTH.0001.4000.1791 Results and Processes guide

CTH.0001.4000.2192 Regulatory and Complaints Statistics

1-39 WIT.0023.9999.0001 Corrigendum to the Statement of Janet Mary Anderson

1-40 WIT.0016.0001.0001 Statement of Dr Harry Nespolon

1-41 RCD.9999.0001.0001 Medical Care of Older Persons in Residential Aged Care Facilities

1-42 RCD.9999.0016.0001 Health Factsheet, Medication Management Reviews

RCD.9999.0007.0128 Medicare Item 903 Processed from July 2017 to June 2018

1-43 RCD.9999.0006.0001 Abuse and Violence - Working With Our Patients in General Practice 4th Ed

Day 6 – 19 February 2019

Exhibit Number

Document Number

Exhibit

1-44 WIT.0005.0001.0001 Statement of Maree McCabe

DEH.0001.0001.0001 Economic Cost of Dementia in Australia

DEH.0001.0001.0005 Redesign of Dementia Consumer Supports, Submission from Dementia Australia November 2017

DEH.0001.0001.0006 The Use of Restraints and Psychotropic Medications in People with Dementia

DEH.0001.0001.0007 Inquiry into the Quality of Residential Aged Care

DEH.0001.0001.0008 The Future of Work and Workers, January 2018

DEH.0001.0001.0009 Palliative Care and Dementia, Dementia Australian Paper Number 43

DEH.0001.0001.0010 Submission to Aged Care Legislated Review, December 2016

DEH.0001.0001.0011 Caring for Someone with Dementia, October 2015

DEH.0001.0001.0014 Younger Onset Dementia - Bridging the Gap, August 2017

DEH.0001.0001.0017 Dementia and the Impact of Stigma

1-46 WIT.0013.0001.0001 Statement of Sean Thomas Rooney

LAS.0001.0001.0002 LASA Representation on External Committes.

LAS.0001.0001.0004 LASA Constitution (adopted 9 Oct 2016)

LAS.0001.0001.0006 LASA Director biographies

DEH.0001.0001.0016 Inclusion and Isolation, September 2018

1-45 WIT.0014.0001.0001 Statement of Patricia Ann Sparrow

LAS.0001.0001.0001 LASA Submissions List

LAS.0001.0001.0003 LASA Membership Brochure

LAS.0001.0001.0005 LASA Governance Structure

59

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

LAS.0001.0001.0008 List of Previous Reviews

LAS.0001.0001.0009 Aged Care Matters Diagram.

LAS.0001.0001.0011 LASA Model Understanding Consequences

LAS.0001.0001.0013 Submission Appendix 1:Tune Prudential Recommendations

LAS.0001.0001.0014 LASA Summary of the HCP Data Report for 1st Quarter to 30 Sept 2018

LAS.0001.0001.0015 Aged Care Alternative Funding Solution - LASA (9 Nov 2016)

LAS.0001.0001.0017 LASA pre-budget submission

LAS.0001.0002.0001 LASA Members as at 6 February 2019

LAS.0001.0002.0003 LASA Advisory structures

LAS.0001.0002.0005 LASA professional development workshops, conferences, and webinars

LAS.0001.0002.0007 LASA snapshot of activities

LAS.0001.0002.0009 Use of restraints - updated questions for providers

LAS.0001.0002.0011 AACQA Survey Response Booklet V2

1-48 RCD.9999.0017.0001 Single Aged Care Quality Framework April 2017

1-49 RCD.9999.0018.0001 Department of Health Single Aged Care Quality Framework Draft Aged Care Quality Standards Consultation Paper 2017

1-50 WIT.0011.0001.0001 Statement of Nicolas George Mersiades

ACQ.500.001.0001 Catholic Health Australia, Aged Care Update - “Let’s talk ACFI and funding volatility”

ACQ.500.001.0101 Catholic Health Australia, Aged Care Update - “It’s time to ring respite services into the reform equation”

ACQ.500.001.0201 Catholic Health Australia, Aged Care Update - “Will the current aged means testing arrangements fit the bill?”

LAS.0001.0001.0010 ACFA Diagram

LAS.0001.0001.0012 LASA Submission to government on Tune report

LAS.0001.0001.0016 LASA Submission to strategic imperatives

1-47 WIT.0024.0001.0001 Second Statement of Sean Thomas Rooney

LAS.0001.0002.0002 New Aged Standards Fusion flyer

LAS.0001.0002.0004 LASA Submissions 2016 to present

LAS.0001.0002.0006 LASA Accredited training activities

LAS.0001.0002.0008 Use of Restraints - Guidelines Update and Member Survey

LAS.0001.0002.0010 LASA Member Surveys

LAS.0001.0002.0012 Appendix Aged Care Provider Roundtable Report Executive Summary July 2018

60

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Day 7 – 20 February 2019

Exhibit Number Document Number

Exhibit

1-51 WIT.0010.0001.0001 Statement of Claerwen Eleanor Little

UCH.500.001.0101 UnitingCare Australia, Attitudes Towards the Aged Care Sector, December 2018

UCH.500.001.0201 UnitingCare Australia, Aged Care Data Project – Module 1, October 2018

1-52 WIT.0018.0001.0001 Statement of Melissa Coad

1-53 UVH.0002.0001.0001 United Voice Home Care Member Survey 2017

1-54 WIT.0012.0001.0001 Statement of Matthew Graham Richter

1-56 WIT.0015.0001.0001 Statement of Dr Anthony Bartone

1-58 RCD.9999.0019.0003 AMA Aged Care Survey Report 2017

1-59 RCD.9999.0019.0001 AMA Position Statement entitled Restraint in the Care of People in Residential Aged Care Facilities

Day 8 – 21 February 2019

Exhibit Number Document Number

Exhibit

1-60 WIT.0019.0001.0001 Statement of Gerard John Hayes

1-61 WIT.0031.0001.0001 Statement of Kaye Frances Warrener

KWH.9999.0001.0001 HCP Assignment Letter

KWH.9999.0001.0004 HCP Readiness Letter

KWH.9999.0001.0006 Eligibility for Australian Government subsidised aged care letter

1-62 WIT.0053.0001.0001 Statement of Margaret Jane Harker

1-63 WIT.0030.0001.0001 Statement of Barrie Anderson

1-64 ACW.9999.0002.0001 Royal Commission Letter to Professor Pollaers inviting a response dated 14 February 2019

ACW.9999.0001.0001 Response of Professor John Pollaers dated 20 February 2019

1-55 WIT.0029.0001.0001 Supplementary Statement of Mr Richter

1-57 WIT.0027.0001.0001 Additional Statement of Dr Bartone

61

Appendix 4 Exhibits

Adelaide 2

Day 10 – 18 March 2019

Exhibit Number Document Number

Exhibit

2-1 WIT.0072.0001.0001 Statement of Lynda Henderson

2-2 RCD.0011.0012.0001 Statement of Dr Stephen Judd (HammondCare)

2-4 WIT.0083.0001.0001 Statement of Raelene Ann Ellis

2-6 RAE.0001.0001.0003 Home Care Package Budget Level 4 for Therese Ellis

2-8 RCD.0011.0014.0001 Opal’s Response to the Evidence of Ellis

2-10 CTH.0001.1000.3881 Application Form for Approval to Provide Aged Care – New Applicant

2-11 CTH.0001.1000.3930 Guidance for Applicants Seeking Approval to Provide Aged Care

2-12 WIT.0078.0001.0001 Statement of Paul Michael Sadler

2-13 RCD.0011.0010.0017 Presbyterian Aged Care Home Care Services Price List Effective January 1 2019

2-14 RCD.0011.0010.0001 Elder Abuse ACSA Position Paper dated November 2016

Day 11 – 19 March 2019

Exhibit Number Document Number

Exhibit

2-15 WIT.0068.0001.0001 Statement of Josef Rack

2-16 SCC.002.001.0283 Care Recipient Agreement Between Mr Rack and Southern Cross Care

2-17 SCC.002.001.0171 Consumer Agreement Between Mr Rack and Southern Cross Care

2-18 JRA.0002.0001.0004 Undated Aged Care Package Agreement Between Assist and Mr Rack

2-19 JRA.0002.0001.0036 Assist Home Care Spreadsheet

2-20 JRA.0002.0001.0134 Handwritten Note Prepared by Mr Rack Regarding Correctness of Material in the Spreadsheet

2-21 JRA.0002.0001.0080 Letter from Department of Health to Mr Rack dated 9 October 2018

2-22 HEN.0001.0001.0098 Home Care Agreement Between Hendercare Pty Ltd and Mr Rack dated 31 October 2018

2-23 RCD.0011.0009.0131 Statement Signed by David Moran and Caroline Ford on Behalf of Southern Cross Care

2-24 RCD.0011.0009.0015 Mr Rack - Analysis of Schedule

2-25 WIT.0071.0001.0001 Statement of Claire Lynette Hargreaves

2-26 WIT.0082.0001.0001 Statement of Sally Francis Warren

2-3 LHE.0001.0001.0001 Video of Lynda Henderson and Veda Meneghetti

2-5 RAE.0001.0001.0002 Home Care Package Statement for Therese Ellis

2-7 RAE.0001.0001.0001 Photograph of Ellis and Her Mother

2-9 WIT.0087.0001.0001 Statement of BE

62

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Number Document Number

Exhibit

2-27 WIT.0080.0001.0001 Statement of Heather Virginia Jackson

2-28 WIT.0081.0001.0001 Statement of Anna Gabrielle Hansen

2-29 WIT.0079.0001.0001 Statement of Rosemary Anne Dale

2-30 RCD.0011.0011.0001 Written Response of Australian Unity to the Witness Statement of Rosemary Anne Dale Fwd Under Cover of a Letter from Allens to the Commission Solicitors dated 13 March and Attachments Thereto

RCD.0011.0011.0002 Australian Unity Response to Statement of R Dale

RCD.0011.0011.0009 Attachment A - Current Roster

RCD.0011.0011.0010 Attachment B - Employee Visit History Report

RCD.0011.0011.0011 Attachment C - Training Attendance List

RCD.0011.0011.0012 Attachment D - MoveSafe Course Attendance Sheet

RCD.0011.0011.0015 Attachment E - Training Record of Completed Learning Modules

RCD.0011.0011.0016 Attachment F - Care Workers Externally Recognised Qualifications

RCD.0011.0011.0018 Attachment G - Historical Rosters

RCD.0011.0011.0048 Attachment H - Timekeeping Report

RCD.0011.0011.0051 Attachment J - Home Safety Checks

RCD.0011.0011.0057 Attachment K - Enterprise Agreement

2-31 CTH.1002.1001.3084 Australian Aged Care Quality Agency Contact Report relating to Assist Home Care dated 17 May 2018

2-32 CTH.1002.1001.3146 Australian Aged Care Quality Agency Final Quality Report into Assist Home Care dated 28 September 2018

Day 12 – 20 March 2019 Exhibit Number Document

Number

Exhibit

2-33 WIT.0033.0001.0001 Statement of BC 2-34 WIT.0077.0001.0001 Statement of Marie Dowling 2-35 MDO.0001.0001.0005 Letter from My Aged Care to Marie Dowling dated 23 March 2018 2-36 WIT.0076.0001.0001 Statement of BA 2-37 WIT.0084.0001.0001 Statement of Mary Patetsos

MPA.0001.0001.0001 National Ageing and Aged Care Strategy for People from Culturally and Linguistically Diverse (CALD) Backgrounds MPA.0001.0001.0024 Chapter 14 - Aged Care Services

MPA.0001.0001.0210 National Aged Care Data Clearinghouse Data Dictionary MPA.0001.0001.0267 Cultural and linguistic diversity measures in aged care

MPA.0001.0001.0434 Exploring the aged care use of older people from culturally and linguistically diverse backgrounds: a feasibility study MPA.0001.0001.0457 Review of Australian Research on Older People from Culturally and Linguistically Diverse Backgrounds MPA.0001.0001.0551 Home Care Packages Program Data Report 4th Quarter 2017-18

63

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

2-38 RCD.0011.0018.0001 Aged Care Diversity Framework dated December 2017 2-39 RCD.9999.0025.0001 ABS 2016 Census Quick Stats 2-40 CTH.1002.1016.2502 Letter from Department of Health to BC Titled Application for Approval as an Approved Provider dated 5 May 2017

2-41 CTH.1002.1016.1731 Email from Department of Health to BC Subject Application to Become an Approved Provider dated 6 February 2017 2-42 CTH.1002.1016.1694 Email from Department of Health to BD Pty Subject Requirement to Give Further Information dated 6 March 2018 2-43 CTH.1002.1016.1689 Letter from Department of Health to BD Pty Ltd Titled

Reconsideration of Deemed Decision to Reject Application for Approval as an Approved Provider

2-44 CTH.4000.1003.2094 Email from Department of Health to BD Pty Ltd Subject Failure to Meet the Home Care Standards dated 19 November 2018 2-45 CTH.4000.1003.2096 Australian Aged Care Quality Agency Assessment Contact Advice dated 31 October 2018 2-46 CTH.1002.1002.0055 Letter from Department of Health to BD Pty Ltd Titled Sanctions

Decision dated 8 November 2018

2-47 CTH.1002.1008.0729 Email from Aged Care Management Australia to Department of Health Forward Subject National Criminal History Check dated 21 November 2018

2-48 CTH.1002.1007.2482 Email from Australian Care Management Australia to BD Pty Ltd titled Confidential Update dated 26 November 2018

2-49 THC.0001.0002.0007 Aged Care Management Australia Service Proposal dated 11 November 2018 2-50 CTH.1002.1016.3173 Untitled Email from BC to Department of Health dated 16 December 2018 2-51 CTH.1002.1007.3400 Email from Department of Health to Compliance Centre West

Forward HNS Transfer of Clients dated 15 December 2018

2-52 CTH.4000.1003.2088 Email from Australia Aged Care Quality Agency to BD Pty Ltd titled Confirming Assessment to BD Pty Ltd dated 9 October 2018

2-53 CTH.4000.1003.2089 Information Sheet Attached to 9 October 2018 Email from AACQA 2-54 CTH.4000.1003.2092 Flyer for BD Pty Ltd’s Clients informing them of AACQA’s planned visit on 31 October 2018 2-55 CTH.1002.1001.3863 Australia Government Aged Care Quality Agency Titled Home

Care Assessment Contact Report dated 31 October 2018

2-56 CTH.1002.1016.1582 BD Pty Ltd Application for Approval to Provided Aged Care dated 15/11/16 2-57 CTH.1002.1016.2507 Notice Under S 8-4 Requirement to Give Further Information dated 9 Feb 2017 2-58 CTH.1002.1019.6468 BD Pty Ltd Application for Approval to Provided Aged Care

dated 9 Aug 2017

2-59 CTH.4000.1001.0746 Final Report of ACQSC dated 29/1/19 2-60 THC.0001.0001.0566 Invoice of BD Pty Ltd Second Adviser dated 12 November 2018 2-61 CTH.1002.1007.2644 Email from BC to Health Re New Administrator

dated 4 December 2018

64

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Day 13 – 21 March 2019

Exhibit Number Document Number

Exhibit

2-62 RCD.0011.0019.0001 Email correspondence between Assist Homecare to Josef Rack dated August 2017

2-63 RCD.0011.0019.0003 Email from Assist Homecare to Josef Rack dated 27 October 2017

2-64 RCD.0011.0019.0004 Email correspondence between Assist Homecare And Josef Rack dated 1 December 2017 enclosing Statement and invoices

2-65 RCD.0011.0019.0011 Email from Assist Homecare to Josef Rack dated 6 December 2017 enclosing statement

2-66 RCD.0011.0019.0015 Email correspondence between Assist Homecare And Josef Rack dated 29 January 2018

2-67 RCD.0011.0019.0017 Email correspondence between Assist Homecare to Josef Rack dated 2 February 2018

2-68 RCD.0011.0019.0019 Email from Assist Homecare to Josef Rack dated 5 February 2018

2-69 RCD.0011.0019.0020 Email Correspondence between Assist Homecare and Josef Rack dated 7 February 2018

2-70 RCD.0011.0019.0021 Email Correspondence between Assist Homecare and Josef Rack dated April 4 April 2018 enclosing Statement and invoices

2-71 RCD.0011.0019.0032 Email Correspondence between Assist Homecare and Josef Rack dated 5 April 2018

2-72 RCD.0011.0019.0033 Email from Assist Homecare to Josef Rack dated 28 May 2018 enclosing invoice

2-73 RCD.9999.0026.0001 Census 2016

2-75 JRA.0002.0001.0435 Southern Cross Care January 2017 Statement

2-77 RHA.0001.0001.0001 Letter from the Department of Health to Mrs Joyce Edwards dated 11 November 2018

2-78 WIT.1066.0001.0001 Statement of Graeme Barden

2-79 CTH.0001.1000.4974 Summary of the approval process for home care provider applicants under the Aged Care Act prepared by the Department of Health

2-80 WIT.0088.0001.0001 Statement of Rita May Kersnovske

2-81 CTH.1000.1015.0227 National Aged Care Compliance Program Decision-Making Procedure

2-82 CTH.1000.1019.3267 National Aged Care Compliance Program Procedure for Imposition of Sancitions, Immediate and Severe Risk

2-83 CTH.1000.0002.6095 Chronology of events for each provider the subject of NTP-0016

2-84 CTH.1002.1001.3860 Email exchange between the Quality Agency and the Department dated 7 November 2018

2-74 JRA.0002.0001.0432 Southern Cross Care December 2016 Statement

2-76 WIT.0074.0001.0001 Statement of Ruth Harris

65

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

2-85 CTH.1002.1007.1974 Email exchange between an officer of the Department and an officer of the compliance organisation dated 7 November 2018

GRA.0001.0001.0001 26-aged-care-appendix

GRA.0001.0001.0213 Broad et al 2015

GRA.0001.0001.0219 Discussion Paper - Streamlined Consumer Assessment for Aged Care

GRA.0001.0001.0238 General-Practice-and-Primary-Care-Clinical-Committee- Phase-2-Report

GRA.0001.0001.0384 HCP Data Report 2017-18 4th Quarter Revised

GRA.0001.0001.0414 Intergenerational challenges

GRA.0001.0001.0440 Learning from Japan Final

GRA.0001.0001.0500 Long Term Care Insurance

GRA.0001.0001.0532 Stewart Brown ACFPS Sector Report June 2018

GRA.0001.0001.0570 Swerissen Duckett Dying well report

GRA.0001.0001.0607 Wollongong paper

Day 14 – 22 March 2019

Exhibit Number Document Number

Exhibit

2-87 WIT.0035.0001.0001 Statement of Jason Howie

2-88 WIT.0034.0001.0001 Statement of Amanda Bowe

2-89 WIT.0058.0001.0001 Statement of Fiona Kathryn Buffinton

2-90 CTH.1000.0001.2056 Business Plan of the In Home Care Division of the Department of Health dated June 2018

2-91 CTH.0001.1000.4836 Department of Health Guidance on Priority for Home Care Services

2-92 RCD.9999.0028.0001 Home Care Packages Program Report for Period 1 October 2018 To 31 December 2018 dated March 2019

2-94 JRA.0002.0001.0051 Assist Home Care Spreadsheet dated 27 June 2018

2-96 JRA.0002.0001.0092 Assist Home Care Spreadsheet dated 4 December 2018

2-97 JRA.0002.0001.0204 Extract of 2016 Diary of Josef Rack from 24 October 2016 to 31 December 2016

2-98 JRA.0002.0001.0384 Southern Cross Care (SA & NA) Inc CDC and Client Statement as at 30 April 2014

2-99 JRA.0002.0001.0416 Southern Cross Care (SA & NT) Inc CDC and Financial Statement as at 31 March 2016

2-86 WIT.0085.0001.0001 Statement of Professor Hjalmar Swerissen

GRA.0001.0001.0031 ACFA Sixth Report on the Funding and Financing of the Aged Care Sector 2018

2-93 RCD.9999.0030.0001 Figure 9 of the Stewart Brown Report dated March 2018

2-95 JRA.0002.0001.0082 Assist Home Care Spreadsheet dated 25 October 2018

66

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

2-100 JRA.0002.0001.0418 Southern Cross Care (Sa & Nt) Inc CDC and Financial Statement as at 30 April 2016

2-101 RCD.0011.0021.0003 Statement of Peter Vincent and identified annexures

RCD.0011.0021.0035 Statement 24 - Evidence, [BD Pty Ltd] Self Assessment Updated

RCD.0011.0021.0069 FW: LASA Nurse Advisor /Administrator Panel

RCD.0011.0021.0072 Notice of Decision to Impose Sanctions - [BD Pty Ltd]

RCD.0011.0021.0085 Meeting Tomorrow

RCD.0011.0021.0086 ACMA A4 Brochure.pdf

RCD.0011.0021.0088 Statement 58 & 59 - Evidence, Text Message [BC] & Duncan Decision

RCD.0011.0021.0089 Statement 58 & 59 - Evidence, Text Message [BC] & Duncan Decision

RCD.0011.0021.0090 Statement 58 & 59 - Evidence, Text Message [BC] & Duncan Decision

RCD.0011.0021.0091 Statement 58 & 59 - Evidence, Text Message [BC] & Duncan Reconsid

2-102 RCD.0011.0021.0093 Email of P Vincent to Health attaching report dated 3/12/18

2-103 RCD.0011.0021.0094 Report of ACMA dated 3/12/18

Sydney 2 Day 15 – 6 May 2019

Exhibit Number Document Number

Exhibit

3-1 WIT.0107.0001.0001 Statement of Merle Valma Mitchell AM 3-2 General Tender Bundle

RCD.9999.0034.0014 Behavioural and psychological symptoms of dementia: a seven-tiered model of service delivery

CTH.0001.4000.4879 Decision-Making Tool Supporting a Restraint Free Environment in Residential Aged Care

RCD.9999.0033.0015 Behaviour Management A Guide to Good Practice – Managing Behavioural and Psychological Symptoms of Dementia

CTH.1007.1003.4677 Australian and New Zealand Society for Geriatric Medicine Position Statement No. 2 Physical Restraint Use in Older People, Revised September 2012

CTH.0001.1000.5874 Decision-making Tool letter to RACFs

RCD.9999.0033.0001 National Framework for Reducing and Eliminating the Use of Restrictive Practices in the Disability Sector

CTH.0001.1000.5306 Charter of care recipients rights and responsibilities residential care

CTH.0001.1000.5731 KPMG Ministerial Dementia Forum Options Paper

CTH.0001.1000.5652 National Framework for Action on Dementia 2015-2019

67

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

CTH.1000.0002.7376 MS15-002447 - Dementia Programmes Handling Strategy

CTH.1000.0002.6722 MS15-002717 - Dementia Program Redesign

CTH.1000.0002.6576 2016 Ministerial Dementia Forum Discussion Paper - Redesigning Dementia Consumer Supports

CTH.0001.1000.5686 KPMG 2015 Ministerial Dementia Forum Final Report

RCD.9999.0031.0002 Clinical Practice Guidelines and Principles of Care for People with Dementia (Recommendations) - Cognitive Decline Partnership Centre

RCD.9999.0032.0087 RANZCP Professional Practice Guideline 10: Antipsychotic medications as a treatment of behavioural and psychological systems of dementia

CTH.0001.1000.5385 National Aged Care Quality Indicator Program - Resource manual for residential aged care facilities

CTH.1000.0002.6547 MS16-002465 - Release of 2015 Ministerial Dementia Forum Report RCD.9999.0032.0399 Livingston et al, ‘Dementia prevention, intervention, and care’

DEH.0001.0001.0001 Brown et al, ‘Economic Cost of Dementia in Australia 2016-2056’

CTH.0001.1000.5709 KPMG 2016 Ministerial Dementia Forum Final Report

CTH.1000.0002.6654 MS17-000567 - Release of 2016 Ministerial Dementia Forum Report, Redesign of Dementia Consumer Supports and Extension to Existing Arrangements

CTH.1007.1010.0663 Department of Health emails re contact for story quotes

RCD.9999.0031.0001 RANZCP Restraint in Australian and New Zealand Mental Health Acts

CTH.1000.0002.6954 MS17-001608 - National Aged Care Quality Indicator Program

CTH.1007.1010.1242 MB17-003591 Recommendations for prevention of injury- related deaths in residential aged care services (unsigned)

CTH.0001.1000.5761 Severe Behaviour Response Teams (SBRT) Evaluation Final Report

RCD.0010.0001.0022 Findings into death of Margaret Barton CCV 2015

ESG.9999.0005.0001 ANZSGM Position Statement No 28 Dementia in Older People RCD.9999.0032.0093 Bellenger et al, ‘The Nature and Extent of Physical Restraint- related Deaths in Nursing Homes: A systematic review’ RCD.9999.0032.0113 Dyer et al, ‘An overview of systematic reviews of

pharmacological and non- pharmacological interventions of the treatment of behavioural and psychological symptoms of dementia’ RCD.9999.0032.0140 Westaway et al, ‘The extent of antipsychotic use in Australian residential aged care facilities and interventions shown to be effective in reducing antipsychotic use: A literature review’ RCD.9999.0032.0238 OECD ‘Care Needed: Improving the Lives of People with Dementia’ CTH.1000.0002.6383 Westbury et al, ‘RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities’

RCD.9999.0034.0002 Australian Institute of Health and Welfare, Australia’s health 2018, Chapter 3.14

68

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

CTH.1000.0002.6148 Brodaty et al, ‘Antipsychotic Deprescription for Older Adults in Long-term Care: The HALT Study’

CTH.1000.1012.7250 Department of Health emails re psychotropic medication and/or restraint

CTH.1000.1012.7251 Department of Health, table of Psychotropic Medication and Restraint - Residential Aged Care

CTH.1007.1010.5235 Department of Health emails re Department of Health Daily Briefing Tuesday 14 August 2018

CTH.1000.0002.6501 MS18-001835 - Government Response to the Legislated Review of Aged Care 2017 (Tune review) and the Independent Review of National Aged Care Quality Regulatory Processes (Carnell-Paterson review)

CTH.0001.1000.5322 Quality of Care Amendment (Single Quality Framework) Principles 2018

CTH.1007.1010.5923 Department of Health emails re Third Atlas AHMAC

CTH.1007.1002.0034 Aged Care Quality, Safety and Regulation Program Board, Meeting outcome and actions

CTH.0001.1000.5887 Specialist Dementia Care Program framework

CTH.0001.4000.4762 Aged Care Quality and Safety Commission, ‘Results and Processes Guide’

CTH.1007.1010.6787 Department of Health emails re initial meeting on restraint

CTH.0001.4000.4877 Media Release - Safeguarding against inappropriate use of physical or chemical restraint

CTH.0001.1000.5628 Dementia Support Australia, Additional Data Report, No: 4 (1 July 2018 - 31 December 2018)

CTH.1007.1010.7400 Department of Health emails re Charter of Aged Care Rights

CTH.1007.1010.7404 Comparative table - physical and chemical restraint in aged care

CTH.1007.1002.0933 Department of Health emails re today’s MYEFO announcement

CTH.1007.1010.7408 Department of Health emails re Charter of Aged Care Rights

CTH.1007.1002.1961 Department of Health emails re Update on the Clinical Advisory Committee

RCD.9999.0033.0205 Supported decision-making in aged care: A policy development guideline for aged care providers in Australia (second edition)

CTH.0001.1000.5607 Dementia in the Community Report 2019

RCD.9999.0032.0461 Dementia Support Australia ‘Key facts and figures’

CTH.1000.0001.1424 Departmental Structure Chart - 29 June 2018

RCD.9999.0032.0128 Westbury et al, ‘More action needed: Psychotropic prescribing in Australian residential aged care’

CTH.0001.1000.5213 Pharmacological Information - Risperidal (Janssen)

CTH.1007.1002.0939 Department of Health emails re proposed consultation - chemical and physical restraint

CTH.1007.1010.7426 Department of Health emails re definition of physical restraint

69

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

CTH.1007.1002.2055 Department of Health emails re Proposed consultation - chemical and physical restraint

CTH.1000.0002.6407 PBS-RPBS Government expenditure and prescriptions for selected medicines supplied to people aged 65 years and over, 2015-16 to 2017-18

CTH.1007.1002.5461 Department of Health emails re Background info & data for the Aged Care Clinical Advisory Committee

CTH.1007.1002.5844 Department of Health email re Table of Recommendations Restraint

CTH.1007.1002.5845 Table of Recommendations on prevention of the unlawful use of physical and chemical restraints in aged care 8 February 2019

CTH.1007.1002.5868 Department of Health email re Targeted letters to GPs

CTH.1007.1002.5869 Department of Health email re Expansion of the Residential Medication Management Review Program and (2) the Pharmacy Society of Australia’s proposal to embed pharmacists into aged care homes

CTH.1000.0002.6375 Aged Care Clinical Advisory Committee, Agenda item 4 - background information and data

CTH.1000.0002.6397 Aged Care Clinical Advisory Committee, Agenda Item 6 - Non-regulatory options for addressing restraints

CTH.1000.0002.6372 Agenda - Aged Care Clinical Advisory Committee Meeting 26 February 2019

CTH.1007.1003.0397 Talking points - Aged Care Clinical Advisory Committee meeting 26 February 2019

CTH.1007.1003.0205 Aged Care Clinical Advisory Committee, Agenda item 5 - Interventions to reduce the inappropriate use of restraints in residential aged care: regulation of restraint

CTH.1007.1003.2275 Department of Health emails re Chemical and physical restraint

CTH.1007.1003.2494 The Third Australian Atlas of Healthcare Variation, 5.5 Antipsychotic medicines dispensing, 65 years and over

CTH.1000.0002.6225 A guide to deprescribing benzodiazepines

CTH.1007.1004.0673 Department of Health emails re stakeholder meeting on Charter

CTH.1007.1004.7090 Department of Health emails re Options Paper - Aged Care Clinical Advisory Committee

CTH.1007.1004.7095 Aged Care Clinical Advisory Committee - Options Paper Reducing the inappropriate use of chemical restraints in residential aged care (draft, V7)

CTH.1007.1004.7127 Department of Health emails re Options paper - Aged Care Clinical Advisory Committee

CTH.1007.1004.7718 Regulation of restraint in aged care Teleconference, 4 March 2019 (MPConsulting summary)

CTH.1000.0002.6219 A guide to deprescribing antipsychotics

CTH.0001.1000.5602 Dementia in the Community Policy Co-Design Workshop Outputs

70

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

RCD.9999.0034.0006 Harrison et al, ‘Trends in Prevalence of Dementia for People Accessing Aged Care Services in Australia’

CTH.1007.1005.3369 Summary of dicussions of 18 March 2019 working group meeting on Regulating chemical and physical restraint in aged care

CTH.0001.1000.5875 Charter of Aged Care Rights

CTH.1007.1005.5669 Email to Department of Health re LASA Feedback on Regulating Chemical and Physical Restraint

CTH.1007.1005.5671 Regulating chemical and physical restraint in aged care - summary of discussions with LASA comments

CTH.1000.0002.6314 Department of Health emails re Aged Care Clinical Advisory Committee - Meeting Papers CTH.1000.0002.6316 Revised Options paper - Chemical Restraints - members comments - 21 March version

CTH.1007.1005.6726 Aged Care Quality and Safety Commission email re 18 March 2019 workshop outcomes - Regulation of physical and chemical restraints in residential aged care

CTH.1007.1005.6728 Regulating chemical and physical restraint in aged care - summary of discussions with ACQSC comments

CTH.1007.1010.7809 Department of Health emails re Repeat antipsychotic prescription in RACFs

CTH.1007.1005.7859 Department of Health emails re Latest Revised DIs - feedback from working group CTH.1007.1006.2993 Aged Care Quality and Safety Commission email re draft amendments to regulate restraint in residential care

CTH.1007.1006.3966 Preliminary Assessment Form - Restraint use

RCD.9999.0034.0001 Dementia Australia, Dementia Key facts and statistics 2019

CTH.1007.1006.1257 Aged Care Quality, Safety and Regulation Standing Committee, Agenda Item No.5 - Specialist Dementia Care Program

CTH.0001.1000.5194 Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019

CTH.0001.1000.5311 Explanatory Statement, Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019

CTH.0001.4000.4927 Aged Care Quality and Safety Commission, Guidance and Resources for providers to support the Aged Care Quality Standards

CTH.1007.1007.0374 MS19-000631 - Chemical restraint - options paper from the Aged Care Clinical Advisory Committee

CTH.0001.1000.4979 PBS Overview Flowchart

CTH.1007.1006.3963 Emails re Preliminary Assessment Form - Restraint use

CTH.1007.1006.4010 Department of Health emails re 18 March 2019 workshop outcomes - Regulation of physical and chemical restraints in residential aged care

RCD.0010.0001.0044 University of Tasmania Submission to the RCACQS

CTH.1000.0002.6142 Aged Care Clinical Advisory Committee Terms of Reference

71

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

CTH.0001.1000.4980 PBS Online Flowchart

CTH.0001.1000.4984 PBS Rejection Reason and Error Codes (Department of Human Services)

CTH.1000.0002.6793 Scoping paper to consider the future policy options for the National Quality Indicator Program

CTH.0001.1000.5877 Performance reporting Indicators, Measures and Targets - Dementia Behaviour Management Advisory Services (DBMAS)

CTH.0001.1000.5879 Performance reporting Indicators, Measures and Targets - Dementia Training Program (DTP)

CTH.0001.1000.5886 Performance reporting Indicators, Measures and Targets - Severe Behaviour Response Teams (SBRT)

CTH.1007.1006.4547 MS19-000673 - Regulation of Restraint in Residential Aged Care Facilities

RCD.0010.0001.0001 Australian Dental Association NSW Submission to the Royal Commission into Aged Care Quality and Safety

CTH.0001.1000.5911 Department of Health - Overview of regulatory framework applicable to medication management in Australia

RCD.9999.0038.0101 Australian Nursing and Midwifery Federation, National Aged Care Survey 2019 – Final Report RCD.9999.0038.0038 S Banerjee, ‘The use of antipsychotic medication for people with dementia: time for action’ RCD.9999.0038.0001 Qld Public Advocate, Aged Care Quality and Safety in

Australia – submission to the Royal Commission on Aged Care Quality and Safety

3-3 WIT.0113.0001.0001 Statement of Darryl Hilda Melchhart

3-4 WIT.0108.0001.0001 Statement of George Akl

3-6 WIT.0109.0001.0001 Statement of Eresha Dilum Dassanayake

CTH.4001.0002.9898 AACQA Assessment Contact Report re Assessment Contact on 22/01/2016

CTH.4001.1001.0442 Email from Garden View Clinical Nurse Educator to staff re updates

CTH.4001.0003.6847 AACQA Re-accreditation Audit Report of audit conducted 30/01/2018 and 31/01/2018

GVN.0001.0001.1175 Garden View Policy Manual updated 2018

CTH.4001.0004.6799 ACAT assessment report for Terance Reeves

GVN.0001.0001.0146 Garden View Admission Database form for Terance Reeves

GVN.0001.0001.0150 Garden View Admission Form for Terance Reeves

MMC.0001.0001.0002 Admission photograph of Terance Reeves taken by Garden View staff

MMC.0001.0001.0003 Photograph of Terance Reeves taken by family member

3-5 RCD.9999.037.0001 Video of Evidence of Merle Valma Mitchell AM

3-7 Garden View Tender Bundle

CTH.4001.0004.9030 AACQA Re-accreditation decision

GVN.0001.0001.0773 Garden View Medication Policy and Procedure updated 2018

CTH.1006.1003.5095 AACQA Re-accreditation Decision and Statement of Reasons

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Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

GVN.0001.0001.1268 Garden View Respite Care Plan and Assessment form for Terance Reeves

GVN.0001.0001.0152 Garden View Assessment for ADLs for Terance Reeves

GVN.0001.0001.0267 Garden View Bedrail Risk Safety Assesment for Terance Reeves

MMC.0001.0001.0004 Photograph of Terance Reeves taken by family member

GVN.0001.0001.0308 Garden View Diversional Therapy Activities Assessment for Terance Reeves

GVN.0001.0001.0927 Garden View Nurse Initiated Medications record for Terance Reeves

MMC.0001.0001.0005 Photograph of Terance Reeves and grandchild taken by Michelle McCulla

MMC.0001.0001.0006 Screenshot of messages sent between Natalie McCulla, Lillian Reeves and other family members

GVN.0001.0001.1270 Garden View Restraint Authorisation Form for Terance Reeves MMC.0001.0001.0007 Photograph of Terance Reeves, Michelle McCulla and child

MMC.0001.0001.0008 Photograph of Terance Reeves

GVN.0001.0001.0644 Garden View Lifestyle Care Plan for Terance Reeves

MMC.0001.0001.0009 Photograph of Terance Reeves

MMC.0001.0001.0010 Photograph of Terance Reeves

GVN.0001.0001.0646 Garden View Neurological Observation Chart for Terance Reeves

MMC.0001.0001.0011 Photograph of Terance Reeves

MMC.0001.0001.0012 Photograph of Terance Reeves

MMC.0001.0001.0013 Photograph of Terance Reeves

MMC.0001.0001.0014 Photograph of Terance Reeves taken by Natalie Smith

CTH.4001.0004.6817 Residential Medication Management Review conducted re Terance Reeves

GVN.0001.0001.0643 Garden View Nurse Initiated Medications record for Terance Reeves

MMC.0001.0001.0015 Photograph of Terance Reeves and Michelle McCulla

MMC.0001.0001.0001 Statement of Account dated 29/05/2018 issued to Terance Reeves by Cincotta Discount Chemist Carlingford

CTH.4001.0004.0778 AACQA Assessment Contact Report re Assessment Contact on 09/07/2018

MMC.0001.0001.0016 Photograph of Terance Reeves at home

MMC.0001.0001.0017 Photograph of Terance Reeves and grandchild

GVN.0001.0001.0061 Agenda and Minutes of Garden View QMC Meeting

CTH.4001.0004.1387 AACQA Assessment contact advice regarding assessment contact on 09/07/2018 CTH.4001.0004.2072 AACQA Assessment Contact Report re Assessment Contact on 21/08/2018

CTH.4001.0004.1344 Garden View Memo titled ‘Regarding:-Use of Restraints’

CTH.4001.0004.1315 Garden View Response To Assessment Report for Assessment Conducted on 09/07/2018

73

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

CTH.4001.0004.6819 Garden View Policy Manual

CTH.4001.0004.6978 Consent signed by Lillian Reeves for disclosureby Garden View to ABC of information regarding Terance Reeves

GVN.0001.0001.0088 Agenda and Minutes of Garden View QMC Meeting

CTH.4001.0004.6763 Email from Jonathan Shteinman to Aged Care Quality Commission (NSW) re Garden View media

CTH.4001.0004.6972 Response to ABC 7.30 on behalf of Garden View re Terance Reeves

CTH.1006.1000.0586 ACQSC Evidence Record of Review Audit conducted 17/01/2019 to 22/01/2019

GVN.0001.0001.0154 Garden View Statement in response to ABC 7.30 story aired 16 January 2019 CTH.1006.1000.0573 Department of Health file note re consideration of decision to impose sanctions on Garden View

CTH.1006.1000.0585 ACQSC Early release of information to Department of Health re Review Audit of Garden View conducted January 2019

CTH.1006.1000.0672 Department of Health Notice of Decision to Impose Sanctions on Garden View Nursing Home

CTH.1006.1000.0912 Correspondence from Jonathan Shteinman to Department of Health in response to Sanctions Decision

GVN.0001.0001.0602 Garden View Aged Care Response to Review Audit Report and Evidence

CTH.1006.1001.0006 ACQSC Review Audit Report re Review Audit conducted 17/01/2019 to 22/01/2019 CTH.1006.1001.0024 ACQSC Decision to vary period of accreditation following review audit

CTH.1006.1001.0056 ACQSC Serious Risk Decision

GVN.0001.0001.0624 Review of Garden View Policies and Procedures conducted by Pride Living Group

CTH.4001.0004.6767 Garden View Restraint Chart for Terance Reeves

GVN.0001.0001.0142 Garden View Activity Attendance Sheet for Terance Reeves

GVN.0001.0001.0648 Garden View Medical Notes for Terance Reeves

GVN.0001.0001.0868 Garden View Close Monitoring/Red Alert Monitoring Chart for Wandering Residents for Terance Reeves

GVN.0001.0001.0932 Garden View Personal Care and Bowel Chart for Terance Reeves

GVN.0001.0001.1260 Prescriber Order Sheet for Terance Reeves

GVN.0001.0001.1263 Garden View Resident Accident/Incident Form completed re Terance Reeves on 21/05/2018 and 01/06/2018

GVN.0001.0001.1417 Garden View Sleep Assessment chart for Terance Reeves

GVN.0001.0001.0098 Garden View Policy re Accreditation Standard 2 dated 2018

CTH.4001.0004.6809 Garden View Behaviour Monitoring Chart for Terance Reeves

GVN.0001.0001.0278 Garden View Clinical Progress Notes for Terance Reeves

GVN.0001.0001.0833 Medication Signing Sheet for Terance Reeves

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Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

GVN.0001.0001.1600 Garden View bundle of documents including Weight Chart and Body Chart for Terance Reeves and referral by Dr Burkitt of Terance Reeves to geriatrician

GVN.001.001.1908 Letter from Sparke Helmore to Aged Care Royal Commission re response to NTG-0090

GVN.001.001.1904 Garden View response to NTG-0090, being letter from Sparke Helmore to Aged Care Royal Commission

GVN.0001.0001.1856 Garden View response to NTG-0090, being Excel table recording details re staff employed as at 30 June 2018

GVN.001.001.0268 Garden View Behaviour Monitoring Chart for Terance Reeves

GVN.001.001.0833 Medication Signing Sheet for Terance Reeves

GVN.001.002.0273 Training Plan for Garden View Aged Care February 2019

GVN.001.002.0303 Email from Vinod Negi (Pharmacist) to Garden View Nursing Advisor

GVN.001.002.0305 Garden View Compulsory Staff Training Record of Attendance

GVN.001.002.0307 Statement of Account dated 28/07/2018 issued to Terance Reeves by Cincotta Discount Chemist Carlingford

GVN.001.001.1857 Garden View weekly staff rosters from 04/07/2018 to 17/07/2018 GVN.001.001.1889 Garden View daily staff rosters for June 2018

GVN.001.002.0283 Extracts of Doctors’ Communication Book 30/05/18 to 08/06/18 GVN.001.002.0286 Extracts of Doctors’ Communication Book 23/04/18 to 18/07/18 GVN.001.002.0004_E Relevant extracts of Garden View staff handover notes

referring to Terance Reeves

KLL.001.001.0001 AACQA Reaccreditation Report - Consumers’ Experience of the Quality of Care and Services

KLL.001.001.0004 AACQA Reaccreditation Report - Consumers’ Experience of the Quality of Care and Services Summary

KLL.001.001.0033 AACQA Reaccreditation Decision and Statement of Reasons

KLL.001.001.0061 AACQA Assessment Contact Report re Assessment Contact on 09/07/2018

KLL.001.001.0073 AACQA Assessment Contact Report re Assessment Contact on 21/08/2018

KLL.001.001.0082 AACQA Assessment Contact Advice re audit on 09/07/2018

KLL.001.001.0083 Garden View Compulsory Staff Training Register (Dementia Related Training) 2018

KLL.001.003.0001 ACAT assessment report for Terance Reeves

GVN.001.001.0146 Garden View Admission Database form for Terance Reeves

GVN.001.001.0278 Garden View Clinical Progress Notes for Terance Reeves

GVN.001.001.0868 Garden View Close Monitoring and Red Alert Monitoring Chart for Wandering Residents for Terance Reeves

KLL.001.001.0006 AACQA Reaccreditation Audit - Audit Assessment Information

KLL.001.001.0035 AACQA Re-accreditation Audit Report of audit conducted 30/01/2018 and 31/01/2018

75

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

KLL.001.003.0005 Garden View Response To Assessment Report for Assessment Conducted on 09/07/2018

KLL.001.003.0016 Doctor’s Communication Book 18.5.18 – 23.5.18

KLL.001.003.0018 Garden View Post Sanctions Improvements (as at 1 May 2019)

WIT.1085.0001.0001 Statement of Vinod Negi

3-8 WIT.0141.0001.0001 Statement of Lillian Reeves

Day 16 – 7 May 2019

Exhibit Number Document Number

Exhibit

3-9 WIT.0097.0001.0001 Statement of Michelle Lauren McCulla

3-10 WIT.0147.0001.0001 Statement of Natalie Sonya Smith

3-11 WIT.0147.0002.0001 Supplementary Statement of Natalie Sonya Smith

3-12 WIT.0139.0001.0001 Statement of Jayanthi Kannan

3-13 WIT.0146.0001.0001 Statement of Dr Miles Burkitt

3-14 WIT.0145.0001.0001 Statement of Dr Kenneth Wong

3-15 WIT.0137.0001.0001 Statement of Kee Ling Lau

3-16 RCD.0011.0024.0001 Supplementary Statement of Kee Ling Lau

3-17 RCD.9999.0041.0001 Letter from ACRC to Sparke Helmore Lawyers

3-18 RCD.9999.0042.0001 Letter from Sparke Helmore Lawyers to ACRC

Day 17 – 8 May 2019

Exhibit Number Document Number

Exhibit

3-19 Brian King Gardens Case Study Tender Bundle Index

ANC.0001.0006.0034 Rodwell, Joan Med report.pdf

ANC.0001.0004.1907 ROL Physiotherapy Assessment

ANC.0001.0006.0308 Care Plans

CTH.4001.0002.6675 Re-accreditation of decision and Statement of reasons

ANC.0001.0004.1773 ROL Oral and Dental Assessment

CTH.4001.0002.9112 Advice of decision to re-accredit - Brian King Gardens RACS ID: 0041

ANC.0001.0004.1304 GP Care Plan Contribution.pdf

ANC.0001.0004.1779 ROL Oral and Dental Assessment

ANC.0001.0004.1913 ROL Physiotherapy Assessment

CTH.4001.0002.6687 earle ha

CTH.4001.0003.9521 Re-accreditation audit assessment information

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Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document Number Number

Exhibit

CTH.4001.0002.9139 Decision to re-accredit

ANC.0001.0004.1769 Joan Rodwell 2016 Dental Care Plan

ANC.0001.0006.3683 Brian King Gardens emails re CO

ANC.0001.0006.3705 Brian King Gardens emails re CO

ANC.0001.0006.3725 Cosmac Healthcare Jobst Order Form

ANC.0001.0004.1257 The Village Dentist Directives

ANC.0001.0005.0754 Emails re BKG investigation feedback

ANC.0001.0005.0755 Letter from R Farmilo

ANC.0001.0004.1781 ROL Oral and Dental Assessment

ANC.0001.0005.0757 Brian King Gardens emails re CO

ANC.0001.0004.1777 ROL Oral and Dental Assessment

CTH.4001.1001.0382 Letter of Apology

ANC.0001.0005.1184 Brian King Gardens emails re CO toenails

ANC.0001.0001.0651 Emails re CO podiatry - email from DM

ANC.0001.0001.0663 Emails re CO podiatry - email from Raj Kulkarni

ANC.0001.0005.1186 Emails re CO podiatry - email from R Farmilo

ANC.0001.0001.0669 Emails re CO podiatry - email from Raj Kulkarni

ANC.0001.0005.1192 Emails re CO podiatry - email from R Farmilo

ANC.0001.0005.1195 Emails re CO podiatry - email from R Farmilo

ANC.0001.0001.0678 Emails re CO podiatry - email from DM to R Farmilo

ANC.0001.0004.1771 ROL Oral and Dental Assessment

ANC.0001.0004.1905 ROL Physiotherapy Assessment

ANC.0001.0001.2025 Brian King Gardens emails re pain lists

ANC.0001.0001.2409 Brian King Gardens emails re ACFI Charts commenced this week

ANC.0001.0001.2035 Brian King Gardens emails re residents for pain

ANC.0001.0001.2417 Brian King Gardens emails re CO on ACFI

ANC.0001.0006.4106 Brian King Gardens emails re CO

ANC.0001.0006.4113 Brian King Gardens emails re CO

ANC.0001.0001.2469 Brian King Gardens emails re CO

ANC.0001.0004.2022 ACFI Answer Appraisal Pack

ANC.0001.0006.4453 Spreadsheet titled ‘BKG HP list’

ANC.0001.0004.1299 Horsnby Hospital Letter to Dr Margaret Ginger

ANC.0001.0001.4337 Email from Brian King Gardens re pain list review

ANC.0001.0006.4211 Emails from Brian King Gardens re CO

ANC.0001.0006.4225 Emails from Brian King Gardens re for UPDATE

ANC.0001.0001.7483 Emails from Brian King Gardens re pain list review

ANC.0001.0006.4322 Emails from Brian King Gardens re pain list review

ANC.0001.0004.1775 ROL Oral and Dental Assessment

ANC.0001.0002.0351 Emails from Brian King Gardens re CO

ANC.0001.0002.0788 Spreadsheet titled ‘Notification of Resident Transfer’

77

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

ANC.0001.0006.4421 Emails from Brian King Gardens re CO move

ANC.0001.0006.4423 Nantha Podiatry - BKG resident listing

ANC.0001.0006.4432 Nantha Podiatry - BKG resident listing

ANC.0001.0006.4458 Nantha Podiatry - BKG resident listing

ANC.0001.0006.4463 Nantha Podiatry - BKG resident listing

CTH.4001.0004.6724 BKG Accreditation Self Assessment

ANC.0001.0002.5556 Email from Brian King Gardens re CO diet changes

ANC.0001.0002.5559 Emails from Brian King Gardens re CO diet changes

ANC.0001.0002.5560 Change of resident dietary information form

ANC.0001.0002.5557 Email from Cheryl Lee re CO

ANC.0001.0002.5577 Emails re The Village Dentist s CO

ANC.0001.0006.4549 Email from Brian King Gardens re CO

ANC.0001.0006.4550 Emails from Brian King Gardens re CO

ANC.0001.0006.4667 Ezymed Chart CO

ANC.0001.0006.4660 Ezymed Chart CO

ANC.0001.0006.4680 Ezymed Chart CO

ANC.0001.0006.4690 Nantha Podiatry - BKG resident listing

ANC.0001.0004.1360 iCare Progress Notes to 2nd April 2019

ANC.0001.0004.1617 CO pain chart

ANC.0001.0004.1551 CO Resident Medication History

ANC.0001.0004.1649 CO - ExtendedCarePlan - Created 20 Jun 2016

ANC.0001.0004.1671 CO - ExtendedCarePlan - Created 21 Jul 2014

ANC.0001.0004.1690 CO - ExtendedCarePlan - Created 28 Mar 2018

ANC.0001.0004.1716 CO - ExtendedCarePlan - Created 30 Jun 2015

ANC.0001.0004.1629 CO - ExtendedCarePlan - Created 9 Jul 2018

JRO.0001.0002.0004 Joan Rodwell Photos

ANC.0001.0004.0406 Oral and Dental Health - Policy

ANC.0001.0004.0291 Module VIII - Medication Management Procedure - Policy

ANC.0001.0004.0481 Assessment and development of multidisciplinary care plan first 28 days - Policy

ANC.0001.0004.0488 Restraint Procedure - Policy

ANC.0001.0004.0499 Behaviour Management - Policy

ANC.0001.0004.0565 First 28 Days - Day of Entry - Policy

ANC.0001.0004.1569 ROL Falls Risk Assessment

ANC.0001.0006.3679 DL and BKG emails regarding wrong medication and pressure stockings

ANC.0001.0007.0035 BL and BKG emails regarding medication and pressure stockings

ANC.0001.0004.1010 Joan Rodwell Dental Care Plan

ANC.0001.0009.0001 Extended Care Plan 2013

ANC.0001.0009.0092 Care Profile Feb 2013

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

78

Exhibit Document

Exhibit

Number Number

ANC.0001.0009.0151 Module VII from Jan 2012

ANC.0001.0009.0193 Joan Rodwell Life Story

ANC.1000.0001.0091 CO Care Profile

ANC.1000.0001.0228 BKG Competency Assessment - Training log

ANC.1000.0001.0861 BKG email re soft food diet - speech pathologist

ANC.1000.0001.0863 Feedback and Complaints - Policy

ANC.1000.0001.0872 Medication Administration - Policy

ANC.1000.0001.0915 iCare Progress Notes extract - 1 February 2013

ANC.1000.0001.0917 Photo of CO

ANC.1000.0001.0912 iCare Progress Notes extract - 23 April 2019 speech pathologist

WIT.0114.0001.0001 Statement of Tirza Harley

JRO.0001.0003.0001 July 2018 Phone Bill

RCD.9999.0035.0001 BKG aerial

RCD.9999.0035.0002 Google Maps screen shot

ANC.1000.0002.0005 Image of acquarium

ANC.1000.0002.0101 iCare Progress Notes extract - 4 July 2018 3.10pm

ANC.1000.0002.0103 iCare Progress Notes extract - 11 July 2018

ANC.1000.0002.0105 Image of BKG Ground Floor

RCD.9999.0036.0001 Antidepressant treatment in Alzheimer_s disease (Brodaty)

RCD.9999.0036.0003 Sertraline or mirtazapine for depression in dementia (HTA-SADD) (Banerjee et al.)

3-20 WIT.0099.0001.0001 Statement of DM

3-21 WIT.0136.0001.0001 Statement of DL

3-22 WIT.0130.0001.0001 Statement Of Richard Farmilo

3-23 WIT.0154.0001.0001 Supplementary Statement Of Richard Farmilo

ANC.1000.0001.0001 Table of Assessment - Policy

ANC.1000.0001.0096 ACFI Verbal Behaviour Assessment for CO

ANC.1000.0001.0860 BKG email re soft food diet

ANC.1000.0001.0862 iCare Progress Notes extract - oral and dental

ANC.1000.0001.0867 Nutrition for Dementia Care - Policy

ANC.1000.0001.0914 iCare Progress Notes extract - 4 January 2019 speech pathologist

ANC.1000.0001.0916 iCare Progress Notes extract - therapy dogs

ANC.1000.0001.0918 iCare Progress Notes extract - 25 May 2017

RCD.9999.0035.0003 Medicine Handbook Mirtazapine 2013 and 2019

ANC.1000.0002.0100 iCare Progress Notes extract - 4 July 2018 11.30am and 12.19pm

ANC.1000.0002.0102 iCare Progress Notes extract - 9 July 2019

ANC.1000.0002.0104 iCare Progress Notes extract - 18 July 2018

ANC.1000.0002.0106 Image of BKG Level 1

Appendix 4 Exhibits

79

Exhibit Document

Exhibit

Number Number

3-24 WIT.0165.0001.0001 Statement of Anglicare

3-25 SUB.0001.0012.3856 Anglican Community Services response to Royal Commission’s request for information dated January 7 2019

3-26 WIT.0131.0001.0001 Statement of Cheryl Lee

3-27 WIT.0155.0001.0001 Statement of Margaret Ann Ginger

3-28 WIT.0143.0001.0001 Statement of Kathryn Nobes

CAC.0001.0006.0044 Care Services - Behaviour Management

CAC.0001.0006.0001 Resident Physical Aggression Policy

CAC.0001.0006.0139 Process Flowchart No 19 - Minimisation of Restraint

CTH.4001.2004.0248 NSW Nurses association letter to Complaints Commissioner

CAC.0001.0002.0075 Resident Name - CA - ACFI assessment

CTH.4001.0005.2260 AACQA conduct assessment audit

CTH.1006.1000.0167 Oberon Village submission to AACQA

CTH.1006.1000.0078 AACQA Assessment contact report

CAC.0002.0004.0110 Critical Incident Report - Facility Record / File No OV42 - Type of Report Physical Assault

CAC.0002.0004.0116 Internal Oberon Village email discussing AACQA audit

CTH.4001.1001.4683 Oberon Village Action Plan for Improvement

CTH.4001.0003.7361 Oberon Village response to AACQA assessment contact report

CTH.4001.0005.1611 AACQA review audit decision

CAC.0001.0006.0154 Behavioural management training - in service Oberon Village

CTH.1006.1000.0302 Notice of Non-Compliance - Accreditation Standards

CTH.1006.1000.0103 AACQA Assessment contact report

CTH.1006.1003.5954 Department of Health assessment of Oberon submission

CTH.1006.1000.0430 Notice to Remedy Non Compliance

CAC.0001.0002.0051 My Support Plan - CA - Assessment Summary

CTH.1006.1000.0148 AACQA Assessment contact advice

3-29 Oberon Village Case Study

CAC.0001.0006.0091 Process F/Chart 15 - Managing Challenging Behaviour

CAC.0001.0006.0105 Process F/Chart 16 B - Post Incident Management

CAC.0001.0006.0053 Elder Abuse - Mandatory Reporting

CAC.0001.0006.0071 Process Flow Chart - Elder Abuse - Mandatory Reporting

CTH.1006.1000.0010 AACQA Assessment contact report

CTH.4001.0005.1620 AACQA conduct assessment audit

CTH.4001.0005.1697 AACQA Assessment contact report

CTH.4001.0003.8795 Oberon Village response to AACQA assessment contact report

CTH.1006.1000.0422 Department of Health Notice to Remedy non-Compliance

CAC.0001.0002.0048 ACAT Assessment

CTH.1006.1000.0121 AACQA Assessment contact report

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

80

Exhibit Document

Exhibit

Number Number

CAC.0001.0010.0094 Progress Notes - 16 May 2018 - 23 May 2018

CAC.0001.0002.0072 Medication Profile - Facility Oberon Village - CA

CAC.0002.0007.0113 Critical Incident Report - Facility Record / File No OV46 - Type of Report Physical Assault

CAC.0001.0011.0016 Medication Administration History 21/05/18 - 27/06/18

CAC.0001.0010.0082 Progress Notes - 23 May 2018 - 01 June 2018

CAC.0001.0012.0002 Internal Oberon Village email

CAC.0001.0008.0001 Critical Incident Report - Facility Record / File No OV49 - Type of Report Physical Assault

CAC.0001.0010.0056 Progress Notes - 03 Jun 2018 - 05 Jun 2018

CAC.0001.0010.0069 Progress Notes - 01 Jun 2018 - 03 Jun 2018

CAC.0002.0007.0137 Incident / Injury Report - Facility Oberon - CA

CAC.0002.0007.0141 Incident / Injury Report - Facility Oberon - Staff

CAC.0001.0010.0624 Diversional Therapy - Leisure Assessment

CAC.0001.0010.0044 Progress Notes - 05 Jun 2018 - 19 Jul 2018

CAC.0001.0010.0610 Communication / Sensory Needs Assessment

CAC.0001.0010.0587 Sleep Evaluation - Night

CAC.0001.0008.0016 Critical Incident Report - Facility Record / File No OV53 - Type of Report Physical Assault

CAC.0001.0002.0092 Incident / Injury Report - Facility Oberon - CA

CAC.0001.0008.0033 Vital Signs Chart - CA - Start Date 26/05/2018 to End Date 25/06/2018

CAC.0001.0010.0590 Behaviour Assessment

CAC.0001.0008.0029 Progress notes - 22 June 2018

CAC.0002.0007.0149 Incident / Injury Report - Facility Oberon - CC

CAC.0001.0008.0003 Critical Incident Report - Facility Record / File No OV53 - Type of Report Physical Assault

CAC.0001.0002.0088 Incident / Injury Report - Facility Oberon - CA

CAC.0002.0007.0378 Statement of RN re assault 27/06/2018

CAC.0001.0008.0002 Internal Oberon Village email discussing 27/0618 incident

CAC.0001.0010.0100 Progress Notes - 29 Jun 2018

CAC.0001.0002.0070 Full Summary - As at 22/5/2016

CAC.0001.0009.0003 Extended Care Plan for CA

CAC.0001.0010.0109 Barthel Assessment

CAC.0001.0010.0628 Diversional Therapy - Assessment

CAC.0001.0012.0001 Internal Oberon Village email

CAC.0001.0010.0613 Behaviour Assessment

CAC.0001.0008.0031 Progress notes - 22 June 2018

CAC.0001.0010.0592 Behaviour Assessment

CAC.0001.0010.0949 CA - 23 June 2018 - 27 June 2018

CAC.0002.0007.0365 Resident Details - CB - Room 1 - Aged Care Facility Oberon Village - Bed A

Appendix 4 Exhibits

81

Exhibit Document

Exhibit

Number Number

CTH.1006.1000.0155 AACQA Assessment contact advice

CTH.4001.0004.1368 Oberon Village response to AACQA audit information

CTH.1006.1000.0416 Department of Health - no further action

CTH.4001.0005.2257 AACQA Proposed audit schedule

CTH.4001.0005.2038 AACQA re-accreditation audit report

CTH.4001.0004.5737 Oberon Village response to AACQA Un-Announced re-accreditation audit

CTH.4001.0004.6536 AACQA re-accreditation decision

CAC.0004.0001.0002 Oberon Village NTG response to Royal Commission

CAC.0001.0007.0001 Reportable Assaults (Sexual and Physical) Register 10/07/15 - 06/02/19

CAC.0001.0010.0014 Cornell Scale for Depression Assessment

3-30 WIT.0134.0001.0001 Statement Of Cheryl Anne O’connell

3-32 WIT.0102.0001.0001 Statement of DF

3-33 WIT.0135.0001.0001 Statement of Marian Anderson

Day 18 – 13 May 2019

Exhibit Number Document Number

Exhibit

3-34 Bupa Willoughby Case Study Tender Bundle

BPA.001.143.0008 CHC30212 Certificate III in Aged Care - Description

BPA.001.119.6646 FM Res-03.4 Nutrition and Hydration Assessment

BPA.047.029.0887 FM Res-02.6 Map of Life

BPA.001.119.6838 FM Res-2.20 Advance Care Plan

BPA.001.119.6924 FM Res-3.29 Swallowing Assessment

CTH.1006.1000.0412 Department of Health assessment of Oberon Village undertaking to remedy

CTH.4001.0004.2083 Oberon Village re-accreditation application

CTH.4001.0004.5561 AACQA consumer experience survey

CTH.4001.0004.5564 AACQA site udit report evidence

CAC.0002.0007.0578 Incident / Injury Report - CB

WIT.0095.0001.0001 Oberon Village NTG response to Royal Commission

CAC.0005.0001.0001 Annexure A CAC.0005.0001.0001

3-31 RCD.9999.0044.0001 Email chain between Commission staff and various other people relating to availability of O’Connell, that chain occurring on 30 April 2019

BPA.026.017.2005 FM Res 03.6 Physiotherapy Assessment

BPA.001.119.6941 FM Res-4.10 Staff Care Conference Record

BPA.001.119.6884 FM Res-3.17 Abbey Pain Scale

BPA.001.149.0257 FM Res-02.3 Medication Plan

BPA.047.029.0893 FM Res-02.7 Interim Care Plan

82

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Number Document Number

Exhibit

BPA.001.143.0654 HLT54115 Diploma of Nursing - Description

BPA.007.002.8233 FM Res-4.11 Family Conference Record

BPA.019.004.1740 WI Res-02.3 Routine Admission

BPA.012.014.7091 WI Res-02.4 Respite Admission

BPA.049.005.9144 WI Res-02.5 Post-Admission

BPA.049.005.9147 WI Res-02.6 Advanced Care Directive

BPA.001.149.0287 WI Res-4.5.1 Communications and Sensory Loss

BPA.012.003.4595 WI Res-4.10.1 Progress Reporting

CTH.4001.0003.0985 AACQA Assessment Contact Report

BPA.013.036.1010 WI Res-4.3.5 Dysphagia Management

BPA.036.007.5034 WI Res-02.1 Routine Pre-Admission

BPA.001.134.0089 Bupa Types of medication administration policy

BPA.012.010.8949 WI Med-5.1.2 Staff Roles, Responsibilities and Delegations

BPA.001.134.0001 Bupa Medication supplies policy

BPA.001.134.0238 Bupa Medication Manual Glossary policy

BPA.001.134.0308 Bupa Medication service provider policy

BPA.026.010.2117 WI Res-02.7 Notification of General Practitioner and Persons Responsible

BPA.001.126.1275 Bupa Personal hygiene policy

BPA.001.033.2067 Bupa self-assessment report

CTH.4001.0003.1817 Application for Re-Accreditation - Bupa Willoughby

CTH.4001.0003.2219 AACQA Assessment Contact Report

BPA.001.149.0261 FM Res-3.19 Admission Database Assessment

BPA.001.134.1595 Bupa Palliative Care Policy

BPA.036.002.9381 Email attaching - My Aged Care - ACAT assessment

BPA.036.007.2380 My Aged Care - ACAT assessment

BPA.026.015.0187 Work Instruction Vital Signs Monitoring

BPA.001.126.1314 Bupa One to one nursing policy

BPA.026.014.9108 WI Res-4.3.1 Nutrition and Hydration

BPA.001.041.1357 FM Res-1.13 Manual Handling - Mobility Assessment and Plan

BPA.012.010.8613 WI Res-4.7.2 Leisure Interests and Activities

CTH.1002.1020.1992 AACQA re-accreditation audit report

CTH.4001.0003.2301 AACQA audit assessment information

CTH.1002.1020.2015 AACQA re-accreditation audit decision

BPA.001.153.0016 Aged Care Enquiry Form

BPA.007.003.4377 WI Med-5.3.2 Medication Administration Requirements

BPA.001.134.0108 Bupa Medication records policy

BPA.036.007.4189 Email re New Admission -- s DE

BPA.046.016.6236 WI Res-03.2 Care Planning BPA.001.127.0253 Interagency transfer assessment

Appendix 4 Exhibits

83

Exhibit Document Number Number

Exhibit

BPA.001.127.0212 DE discharge referral

BPA.001.127.0150 Signed respite agreement

BPA.001.153.0020 Resident Register

BPA.001.127.0255 Interim Care Plan

BPA.001.127.0248 DE - Home Doctor Service Review

BPA.001.153.0025 Catheter Care Plan

BPA.001.127.0250 DE - Hospital Resuscitation Plan

BPA.036.002.8053 Email attaching Blueberry ward drinks list

BPA.036.002.8054 Blueberry ward drinks list

BPA.001.153.0034 Fax attaching discharge summary

BPA.036.002.7516 Email between swallowing consultant and Bupa

BPA.036.007.3171 Internal Bupa email re DE B15

BPA.001.127.0109 Agreement between Bupa and DE

BPA.001.127.0246 DE - Home Doctor Service Review

BPA.007.001.8908_E Diet Analysis

BPA.007.001.8910_E Abbey pain scale assessment

BPA.001.154.0001 DE - Admission Database Assessment

BPA.001.127.0197 DE - Discharge Referral

BPA.036.002.5165 DE - Handwritten Note entitled Safe Swallowing Tips

BPA.007.001.8508 DE - Manual Handling - Mobility Assessment and Plan

BPA.007.001.8399 DE - Physiotherapy Assessment

BPA.007.001.8471 DE - Diet Analysis

BPA.007.001.8916_E Physiotherapy assessment

BPA.001.127.0252 DE - Incident Report A195839

BPA.001.127.0192 DE - Correspondence from GP

BPA.036.007.2355 Email attaching Blueberry ward drinks list

BPA.036.007.2356 Drinks list for Blueberry ward

BPA.036.007.2333 Internal Bupa email re RE: MAP OF LIFE

BPA.001.127.0191 Death certificate

BPA.001.131.0004 Original death certificate

BPA.001.153.0023 Nutrition & Hydration Assessment

BPA.036.007.2272 Internal Bupa email re A/H GP for DE

BPA.033.002.1745 Internal Bupa email re Overtime

BPA.033.002.1891 Internal email Bupa email re DE passed away

BPA.036.007.2146 Internal Bupa email re Late s DE

ATU.0001.0001.0022 Email between Bupa and family

BPA.007.001.8844_E Bupa Assesment Policy

CTH.4001.1001.3064 Bupa Pain management policy

BPA.050.050.5213 Internal Bupa email re s DE

BPA.041.002.0790 Internal Bupa email re FW: s DE

BPA.041.002.0765 Internal Bupa email re RE: s DE

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Number Document Number

Exhibit

84

ATU.0001.0001.0009 Email between Bupa and family

ATU.0001.0001.0017 Email between Bupa and family

ATU.0001.0001.0011 Email between Bupa and family

CTH.4001.1001.2230 New Aged Care Complaint NSW

BPA.041.002.0119 Fax attaching hospital records

BPA.001.127.0204 Notes from North Shore Hospital treatment

BPA.050.050.5182 Internal Bupa email re RE: DE case

ATU.0001.0001.0026 Email between Bupa and family

ATU.0001.0001.0236 Email between Bupa and family

BPA.001.033.6798 Bupa draft clinical governance review of findings

BPA.001.129.4409 Bupa Improvement Log 4229904

BPA.026.021.0545 WI Incident Management

BPA.036.006.7205 Panacea Education Plan

BPA.001.127.0185 Clinical education attendance record - Panacea

CTH.4001.1001.2554 Bupa Deteriorating Resident training program

BPA.036.006.7095 Education agenda for RNs

BPA.001.127.0186 Clinical education attendance record

CTH.4001.1001.2477 Complaints Commissioner - CU advice sought re Bupa Willoughby and s DE

CTH.4001.1001.2479 Bupa Willoughby response to Complaints Commissioner

CTH.4001.1001.2517 Bupa Palliative Care Pathway policy

CTH.4001.1001.2511 Bupa email to Complaints Commissioner re DE complaint

CTH.4001.1001.2832 Complaints Commissioner internal clinical advice re DE treatment

BPA.007.001.9335 Complaints Commissioner - Notice of Intention to Issue Directions - Bupa Willoughby

BPA.001.129.4301 Bupa Clinical Care audit

BPA.001.129.4303 Bupa Internal Audit Excerpt Summary

BPA.007.001.8782 Response to Complaints Commissioner Notice of Intention to Issue Directions Willoughby

CTH.4001.0004.1286 AACQA assessesment contact report

CTH.4001.1001.2866 Bupa response to Complaints Commissioner

BPA.007.001.8800 Letter from Bupa to DI

BPA.012.019.3754 Internal Bupa email re Audit Outcome Trends for April 2018

CTH.4001.1001.2710 Complaints Commissioner draft findings for DE complaint

CTH.4001.1001.2722 DI response to draft findings of Complaints Commissioner

BPA.001.129.4290 Bupa Improvement Log 429030

BPA.001.129.4291 Bupa Improvement Log 429031

BPA.001.129.4293 Bupa Improvement Log 429033

BPA.001.129.4294 Bupa Improvement Log 429035 BPA.001.129.4302 Bupa Improvement Log 429027

Appendix 4 Exhibits

85

Exhibit Document Number Number

Exhibit

CTH.4001.0004.1291 Complaints Commissioner DE complaint referral

BPA.007.001.8272 Complaints Commissioner final email

BPA.007.001.8227 Bupa letter to DI re apology

BPA.001.120.7535 WI Res-02.1a Commissioning Home Pre-Admission

CTH.1006.1000.0445 AACQA Assessment Contact Advice

CTH.1006.1000.0538 AACQA Assessment Contact Report

CTH.4001.0004.1458 Bupa Leadership meeting minutes

CTH.4001.0004.1447 Bupa Willoughby Response to Assessment Contact Information

CTH.4001.1001.2787 Complaints Commissioner - Bupa Willoughby - Feedback letter to DI

CTH.1006.1000.0551 AACQA Assessment Contact Advice

CTH.1006.1000.0553 AACQA Assessment Contact Report

BPA.001.154.0038 Position Description - Registered Nurse

CTH.1006.1000.0563 AACQA Assessment Contact Advice

CTH.1006.1000.0566 AACQA Assessment Contact Report

BPA.001.131.0006 Patient health summary

BPA.001.139.0014 Bupa effective workload management training slides

BPA.001.109.0015 Bupa NTG response - Model of Care- Guiding Statement

BPA.013.030.4528 Bupa NTG response - Save A Shift Strategy Record

BPA.013.030.4530 Bupa NTG response - Save A Shift Strategy

BPA.006.001.5343 Bupa NTG response - BMoC Presentation

BPA.012.010.9386 Bupa NTG response - Bupa Model of Care

BPA.012.010.9387 Bupa NTG response - Binary spreadsheet

BPA.001.134.2380 Bupa NTG response - Rostering

BPA.001.139.0077 Bupa NTG response - Proposal - Roster and Support Team

WIT.0094.0001.0001 Bupa NTG response

BPA.001.129.4295 Bupa audit and Checklist Schedule

BPA.001.129.4298 Bupa Clinical Care Audit

BPA.001.153.0026 Braden Risk Assessment Scale

BPA.007.001.8433 PANACEA Pain Management Presentation

BPA.001.154.0021 Resident Journey Process Index

BPA.001.143.0040 Graduate Nurse Leadership Program Workbook 2016/2017

BPA.007.001.8617 Bundle of handwritten letters from Bupa Willoughby staff

BPA.001.127.0295 DE - Nursing Progress Notes

BPA.001.127.0220 DE - Doctor Notes

BPA.001.155.0005 DE - Activity Attendance Record July 2017

BPA.001.127.0257 DE - Medication Charts

BPA.007.001.8342 DE - Consultation Notes

BPA.007.001.8397 DE - Abbey Pain Scale

BPA.001.145.0003 DE - Daily Food Intake Record

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Number Document Number

Exhibit

86

BPA.041.002.0699 DE - Behaviour Charts

TEMP.0002.0001.0001 Bupa NTG response – staff list

BPA.041.002.0247_E Diet Analysis

ATU.0001.0001.0381_E Photograph – bed sore

BPA.041.002.0329_E Enduring Power of Attorney

BPA.001.125.0001 Bupa Willoughby staff roster 07.07.17 – 16.08.17

BPA.041.002.0241_E Skin integrity assessment

3-36 WIT.0190.0001.0001 Statement of DJ

3-38 WIT.0148.0002.0001 Statement of Maureen Mary Berry

3-40 WIT.0126.0001.0001 Statement of Glenn Eric Rees

3-42 RCD.9999.0050.0076 WHO Infographic on Dementia

3-44 WIT.0164.0001.0001 Statement of Amy Tinley

Day 19 – 14 May 2019

Exhibit Number Document Number

Exhibit

3-45 WIT.0124.0001.0001 Statement of Tamar Krebs

3-46 WIT.0123.0001.0001 Statement of Jennifer Lawrence

3-47 WIT.0122.0001.0001 Statement of Lucille Claire O’flaherty

3-48 WIT.0118.0001.0001 Statement of Professor Constance Dimity Pond

3-49 WIT.0019.0001.0001 Statement of Elizabeth Ruby Anne Beattie

3-50 RCD.0011.0026.0001 Supplementary Statement Of Elizabeth Ruby Anne Beattie

3-51 WIT.0121.0001.0001 Statement of Peter Foltyn DPF.0001.0001.0002 Annexure 2b

3-52 WIT.0121.0001.0001 Statement of Lynette Ruth Goldberg

3-53 RCD.9999.0055.0027 Better Oral Health in Residential Care – Professional Portfolio

3-54 RCD.9999.0053.0001 Australia’s National Oral Health Plan 2015-2024

3-55 WIT.0129.0001.0001 Statement of Brendan Francis Murphy

3-56 RCD.9999.0049.0290 National Residential Medication Chart V3

BPA.036.002.9382 My Aged Care – ACAT assessment

BPA.041.002.0243_E Nutrition and Hydration assessment

3-35 WIT.0101.0001.0001 Statement of DI

3-37 WIT.0148.0001.0001 Statement of Timothy James Ross

3-39 RCD.9999.0049.0016 Guidelines for a Palliative Approach in Residential Aged Care

3-41 RCD.9999.0050.0001 WHO Global Action Plan on the Public Health Response to Dementia 2017-2025

3-43 WIT.0154.0001.0001 Statement of Richard Farmilo

Appendix 4 Exhibits

87

Day 20 – 15 May 2019

Exhibit Number Document Number

Exhibit

3-57 WIT.0152.0001.0001 Statement of Elizabeth

3-58 WIT.0151.0001.0001 Statement of Margaret Ellen Bain

3-59 WIT.0153.0001.0001 Statement of Susan Marie Walton

3-60 WIT.0149.0001.0001 Statement of Suzanne Wendy Wilson

3-61 WIT.0117.0001.0001 Statement of Juanita Westbury

3-62 RCD.9999.0057.0001 Dr Westbury Submission Re Standards

3-63 RCD.9999.0054.0001 Emails between Dilum Dassanayake and Izabela Bozym

3-64 RCD.9999.0056.0001 Scenario Summary One

3-65 RCD.9999.0056.0007 Scenario Summary Two

3-66 RCD.9999.0056.0012 Scenario Summary Three

RCD.9999.0056.0017 Attachment to Scenario Summary Three

3-67 RCD.9999.0056.0018 Scenario Summary Four

3-68 WIT.0125.0001.0001 Statement of Stephen Macfarlane

Day 21 – 16 May 2019

Exhibit Number Document Number

Exhibit

3-69 RCD.9999.0060.0001 University Of Tasmania titled Reducing Use of Sedatives

3-70 WIT.0115.0001.0001 Statement of Joseph Elias Ibrahim

3-71 RCD.9999.0063.0145 Recommendations for Prevention of Injury-Related Deaths in Residential Aged Care Services.

3-72 RCD.9999.0063.0131 Premature Deaths of Nursing Home Residents: An Epidemiological Analysis.

3-74 RCD.9999.0059.0001 Safety First Sketch Diagram

3-76 CTH.1007.1006.3871 Email Exchange From Amy Laffan to Christina Bolger

3-78 WIT.0105.0001.0001 Statement of Amy Elizabeth Laffan

3-73 RCD.9999.0063.0137 Residential Aged Care Communique, Volume 11, Issue 4.

3-75 WIT.0106.0001.0001 Statement of Christina Mary Bolger

3-77 RCD.9999.0062.0001 Letter to Royal Commission (L Amundsen)

3-79 WIT.0144.0001.0001 Statement of Josephine Mond

88

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Day 22 – 17 May 2019

Exhibit Number Document Number

Exhibit

3-80 WIT.0116.0001.0001 Statement of Henry Brodaty

3-81 RCD.9999.0064.0001 La Trobe University, The Person-Centred Care Assessment Tool (P-Cat)

3-83 RCD.0011.0025.0001 Second Supplementary Statement of Richard Farmilo

3-85 RCD.9999.0063.0001 Who Guidelines: ‘Risk Reduction of Cognitive Decline and Dementia’ (16 May 2019)

3-86 RCD.9999.0061.0325 Convention on the Rights Of Persons With Disabilities and Optional Protocol

Broome

Day 23 – 17 June 2019

Exhibit Number Document Number

Exhibit

4-1 General Tender Bundle for Broome Hearings

RCD.9999.0069.0037 LoGiudice et al, Lungurra Ngoora - a pilot model of care

RCD.9999.0075.0001 AAG Towards an Action Plan for Aged Care for Rural And Remote Australia

RCD.9999.0069.0054 Smith et al, High prevalence of dementia and cognitive impairment in Indigenous Australians

RCD.9999.0069.0001 Flicker and Holdsworth, Aboriginal and Torres Strait Islander People and Dementia: A Review of the Research

RCD.9999.0075.0029 ACFA update on funding and financing issues in the residential aged care industry

RCR.0001.0001.0029 North West Ageing and Aged Care Strategy

RCD.9999.0075.0294 Providing Aeromedical Care to Remote Indigenous Communities

RCD.9999.0075.0478 Indigenous Services Study: Lungurra Ngoora Community Care Final Report

RCD.9999.0075.0470 Considerations in culturally safe care for indigenous people with dementia in Canada

RCD.9999.0075.0565 A Community-based Approach to Addressing Caregiver Strain in Indigeous Caregivers of People With Dementia

RCD.9999.0075.0589 Adapting the Kimberly Indigenous Cognitive Assessment for use with Indigenous Older Adults in Canada

RCD.9999.0075.0564 A Community-based Approach to Addressing Caregiver Strain in Indigenous Caregivers of People with Dementia

RCD.9999.0069.0048 LoGiudice et al, Preliminary evaluation of the prevalence of falls, pain and urinary incontinence in remote living Indigenous Australians over the age of 45 years

3-82 WIT.0142.0001.0001 Statement of Trevor Douglas Crosby

3-84 WIT.0127.0001.0001 Statement of Kate Swaffer

89

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

RCD.9999.0075.0566 Does more equitable governance lead to more equitable health care? A case study based on the implementation of health reform in Aboriginal health Australia

CTH.0001.1000.6244 2018-19 Aged Care Approvals Round Essential Guide

RCD.9999.0072.0181 MMM Classification and ASGS Remoteness Areas maps

RCD.9999.0075.0585 LoGuidice, The health of older Aboriginal and Torres Strait Islander peoples

RCD.9999.0075.0230 Australian National Audit Office, ANAO Report No 53 of 2016-17, Indigenous Aged Care Department of Health and Australian Aged Care Quality Agency

CTH.0001.1000.6758 Modified Monash Model - geographical classifications

CTH.0001.1000.6759 Home Care Packages: Wait times

CTH.0001.1000.6763 Recipients of the Viability Supplement

CTH.0001.1000.6785 KPMG Final Report: Department of Health - Challenges and opportunities in delivering aged care services in remote regions

CTH.0001.1000.6377 NATSIFAC Program 2018-19 Residential - Expansion Round Grant Opportunity GO1917

CTH.0001.1000.6431 NATSIFAC Program 2018-2019 Home Care - Expansion Round Grant Opportunity GO1606

CTH.0001.1000.6485 NATSIFAC Program Manual 2018

CTH.0001.1000.6525 Fact Sheet: Aboriginal and Torres Strait Islander peoples’ use of aged care services

CTH.0001.1000.6608 NATSIFAC Program Entry Pathway

CTH.0001.1000.6609 NATSIFAC Program Exit Pathway

CTH.0001.1000.6650 Remote Aboriginal and Torres Strait Islander Aged Care Service Development Assistance Panel fact sheet

CTH.0001.1000.6653 Aged Care Diversity Framework - Aged Care Sector Committee Diversity Sub-group

CTH.0001.1000.6528 Service Development Assistance Panel Workshop Brochure

CTH.0001.1000.6569 Service Development Assistance Panel Information for Service Providers Newsletter 7 July 2017

CTH.0001.1000.6669 Dementia and Aged Care Services Fund: National Aboriginal and Torres Strait Islander Flexible Aged Care Program - 2018- 19 Bi-Annual One-Off Grant Opportunity Guidelines

CTH.0001.1000.5981 National Quality Improvement Framework for Multipurpose Services

CTH.0001.1000.6070 Better Access to Care - aged care system navigator

CTH.0001.1000.6071 Media Release $2 Million for Remote Aged Care Workforce

CTH.0001.1000.6072 Media Release Seniors to Benefit from Remote Aged Care Workforce Accord

CTH.0001.1000.6078 Transition Care Programme Guidelines 2015

CTH.0001.1000.6234 Shared actions to support all diverse older people: A guide for aged care providers

90

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

RCD.9999.0078.0001 Gudiance and Resources for Providers to support the Aged Care Quality Standards

CTH.0001.1000.5993 Request for Tender

RCD.9999.0075.0549 Smith et al, Gotta be sit down and worked out together’; views of Aboriginal caregivers and service providers on ways to improve dementia care for Aboriginal Australians

RCD.9999.0072.0001 Final Report - Indian Ocean Territories Health Service

RCD.9999.0069.0031 Hyde Z et al, Prevalence and incidence of frailty in Aboriginal Australians, and associations with mortality and disability

RCD.9999.0075.0424 Healthy Ageing in Rural and Remote Australia: Challenges to overcome

RCD.9999.0075.0058 ACFA Financial Issues Affecting Rural and Remote Aged Care Providers

RCD.9999.0075.0166 AIHW Insights into vulnerabilities of Aboriginal and Torres Strait Islander people aged 50 and over

ARR.600.001.0007 ‘TJB-2’ Map of Pinangba services across Queensland

ARR.600.002.0001 ‘CRB-1’ Map of ARRCS services in the Northern Territory

RCD.9999.0075.0410 Do Indigenous Australians age prematurely? The implications of life expectancy and health conditions of older Indigenous people for health and aged care policy

RCD.9999.0075.0417 Indigenous aged care service use and need for assistance: Howwell is policy matching need?

RCD.9999.0075.0472 Timely Diagnosis for Dementia: The Need for Specialists

RCD.9999.0075.0474 Using Evidence to Guide the Diagnosis and Management of People With Dementia

RCD.9999.0075.0575 Incidence and predictors of cognitive impairment and dementia in Aboriginal Australians: A follow-up study of 5 years

RCD.9999.0077.0001 Photos of ACS centres in the APY lands

RCD.9999.0078.0196 Kimberley and Far North Queensland for Opening

RCD.9999.0078.0199 Kimberley graphs, Indigenous, OS and ESL

RCD.9999.0078.0200 Torres Strait Islands Map

RCR.0001.0001.0001 Request for exemption from individualised budgeting for clients in remote Aboriginal communities, WA Country Health Services

RCR.0001.0001.0022 Submission Template Increasing Choice in Home Care - Stage 1 Discussion Paper

CTH.0001.1000.6756 Residential and home care services receiving the viability supplement as at February 2019

CTH.0001.1000.6757 Organisations receiving funding through CHSP in regional and remote areas in 2017-18

ARR.600.001.0001 ‘TJB-1’ Map of ARRCS services in the Northern Territory

ARR.600.001.0008 ‘TJB-3’ Star of the Sea residential aged care facility, Thursday Island

91

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

CTH.0001.1000.6848 MPS and NATSIFAC Program services receiving the viability supplement as at February 2019

CTH.0001.1000.6849 Provider transfers between 1 January 2013 and 31 December 2018

RCD.9999.0080.0001 Map of the Kimberley Aged Care Planning Region

RCD.9999.0069.0058 Smith K, Flicker L, Shadforth G, et al ‘Gotta be sit down and worked out...

RCD.9999.0070.0001 Incidence and predictors of cognitive impairement and dementia in Aboriginal Australians: A follow-up study of 5 years

RCD.9999.0074.0001 CAEPR Indigenous Population Project 2011, Census Papers Paper 14

RCD.9999.0079.0001 CAEPR Indigenous Population Change in the 2016 Census, Census Paper 1

RCD.9999.0081.0001 Aged care comparison graphs

RCD.9999.0083.0001 KICA 2017 revised

RCD.9999.0084.0001 The Healing Foundation and AAG’s Aboriginal and Torres Strait Islander Ageing Advisory Group Joint Statement - 7 June 2019

SUB.0001.0012.3594_E ACRC Provider Response - Southern Cross Care (WA) Inc.pdf

RCD.9999.0085.0001 RFDS SPOT Data NRHA 11 April 2018-1

RCD.9999.0086.0001 APY LANDS

RCD.9999.0087.0001 20190617 Standardised MMSE

SCW.0001.0001.0014 Southern Cross Care Complaint Resolution Report

SCW.0001.0001.0018 Letter from the Aged Care Complaints Commissioner with Attachment A Feedback on the Resolution Process dated 6 April 2018.PDF

VCU.0001.0001.0001 Attachment 1 - CHHHS Country Poster

VCU.0001.0001.0002 Attachment 2 - Statement to the Australian Government on the Inquiry into Language Learning in Indigenous Communities

VCU.0001.0001.0013 Attachment 3 - Submission to the Productivity Commission

CTH.0001.1000.6769 List of Organisations receiving funding through the NATSIFAC Program

CTH.0001.1000.6753 Spreadsheet of aged care services operating as a Multi-Purpose Service in Australia

4-3 WIT.1144.0001.0001 Statement of Yvonne Grosser

4-5 WIT.0166.0001.0001 Statement of Tamra Jade Bridges

4-6 WIT.0161.0001.0001 Statement of Professor Leon Flicker

4-2 WIT.1142.0001.0001 Statement of Faye Dean

4-4 WIT.0227.0001.0001 Statement of Craig Robin Barke

92

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Day 24 – 18 June 2019

Exhibit Number Document Number

Exhibit

4-7 WIT.0157.0001.0001 Statement of Martin John Laverty

4-8 WIT.1134.0001.0001 Statement of Graham John Aitken

4-9 WIT.0185.0001.0001 Statement of Ruth Ann Crawford

4-10 WIT.0211.0001.0001 Statement of Belinda Jayne Robinson

4-11 WIT.0185.0001.0001 Statement of Rejane Antoinette Le Grange

4-12 WIT.0256.0001.0001 Statement of Dr Michael Stephen Preece

Day 25 – 19 June 2019

Exhibit Number Document Number

Exhibit

4-13 WIT.1145.0001.0001 Statement of Dr Kate Suzanne Fox

4-14 WIT.1145.0002.0001 Second Statement of Dr Kate Suzanne Fox

4-16 WIT.0243.0001.0001 Statement of Venessa Michelle Curnow

Perth Day 26 – 24 June 2019

Exhibit Number Document Number

Exhibit

5-1 RCD.9999.0071.0001 Statement of Anthony O’donnell 5-2 WIT.0176.0001.0001 Statement of Janet Mary Anderson

5-4 WIT.0226.0001.0005 Statement of Louise Patricia Riley

5-6 WIT.0207.0001.0001 Statement of Karn Nelson

RCD.9999.0067.0068 Southern Cross Care (Tas) Inc. v Secretary, Department of Health and Ageing [2014] AATA 623

CTH.0001.1000.6886 National Consensus Statement Essential Elements for safe high quality end of life care

RCD.9999.0088.0008 Chapman et al - Avoiding costly hospitalisation at end of life: findings from a specialist palliative care pilot in residential care for older adults

RCD.9999.0067.0067 Palliative Approach Toolkit for RACFs - March 2016, Fact Sheet 10

RCD.9999.0067.0001 ACFI Answer Appraisal Pack 2017

RCD.9999.0067.0019 ACFI User Guide 2017

4-15 WIT.0174.0001.0001 Statement of Roslyn Malay

4-17 WIT.0128.0001.0001 Statement of Jaye Alexander Smith

5-3 WIT.0175.0001.0001 Statement of Nigel Murray

5-5 WIT.0168.0001.0001 Statement of Joanne Toohey

5-7 Perth General Tender Bundle

93

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

RCD.9999.0088.0001 Forbat et al - Improving specialist palliative care in residential care for older people: a checklist to guide practice

ALZ.0001.0001.0001 Rae Ellen Letter

CTH.0001.4000.0009 05. Quality of Care Amendment

CTH.0001.1000.6850 National Palliative Care Strategy CTH.0001.4000.4762 Aged Care Quality and Safety Commission, ‘Results and Processes Guide’

CTH.0001.4000.2132 Complaints management process Flow Chart

TOD.0001.0001.0031 Email to Tony O’Donnell Re: An Absence of Care!

TOD.0001.0001.0051 Email to Tony O’Donnell Re: Anti-Dementia Diet!

ALZ.0001.0001.0002 Letter from Dorothy Bennie to Alzheimer’s WA

CTH.0001.4000.7334 Provider letter - 1 July (003)

CTH.0001.4000.7337 Guidance and Resources for Providers to support the Aged Care Quality Standards - Updated 27 May 2019

RCD.9999.0089.0001 Wintringham - Meet the People

ALZ.0001.0001.0021 Hawthorn Elder survey 2018

DFI.0001.0001.0031 My Guidebook

DLT.0001.0001.0062 Gigerenzer, G., Gaissmaier, W., Kurz-Milcke, E., Schwartz, L. M. & Woloshin, S. 2007. Helping Doctors and Patients Make Sense of Health Statistics. Psychological Science in the Public Interest, 8, 53-96

DLT.0001.0001.0107 Needham, C. & Carr, S. 2009. Co-production: an emerging evidence base for adult social care transformation. Research Briefing 31. London: Social Care Institute for Excellence

KCC.0001.0001.0001 1967

KCC.0001.0001.0002 2005

KCC.0001.0001.0003 2019

LCM.0001.0001.0001 Joshua Cohen curriculum vitae

LCM.0001.0001.0009 List of RAC Facilities in the St George and Sutherland Shire region

MAM.0001.0001.0001 Aged Care Community Based Integrated Aged Care Hostels version 6.1

MAM.0001.0001.0032 IUIH Annual Report 2017-18

MAM.0001.0001.0124 Proposed ToRs for Aged Care Royal Commission

TOD.0001.0001.0017 Email to Tony O’Donnell Re: Moving Golaposts!

TOD.0001.0001.0049 Email to Tony O’Donnell Re: Fresh! Fresh! Fresh!

TOD.0001.0001.0048 Email to Tony O’Donnell

CTH.4002.1100.1070 Practices and Processes Guide.

CTH.1000.0002.7516 NTG-0213 Response

ALZ.0001.0001.0004 Hawthorn Employee survey 2018

ALZ.0001.0001.0036 Hawthorn Family survey 2018

DLT.0001.0001.0002 Kumpunen, S., Trigg, L. & Rodrigues, R. 2014. Public reporting in health and long-term care to facilitate provider choice. Policy Summary 13 [Online]. Copenhagen: European Observatory on Health Syste and Policies, World Health Organization

94

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

MAM.0001.0001.0132 Report on the 5th National Workshop of the Aboriginal and Torres Strait Islander Ageing Advisory Group

MAM.0001.0001.0160 Final Consultation Report-Aboriginal and Torres Strait Islander

MAM.0001.0001.0202 IUIH Presentation Adrian Carson for 29 March 2017

RCD.9999.0066.0001 Aged Care Quality Standards Guidance – Standard 6

TOD.0001.0001.0001 Anthony Patrick O’Donnell Submission to the Royal Commission

TOD.0001.0001.0019 Tab 46 - TOD.0001.0001.0019 - Email from Tony O’Donnell

TOD.0001.0001.0020 Photo attached to email from Tony O’Donnell re an absense of care - 1 Sat 09 FEB 2019 2.09pm

TOD.0001.0001.0021 Photo attached to email from Tony O’Donnell re an absense of care - 2 Sat 09 FEB 2019 2.19pm

TOD.0001.0001.0022 Photo attached to email from Tony O’Donnell re an absense of care - 3 Sat 09 FEB 2019 2.19pm

TOD.0001.0001.0023 Photo attached to email from Tony O’Donnell re an absense of care - 4 Sat 09 FEB 2019 2.27pm

TOD.0001.0001.0024 Photo attached to email from Tony O’Donnell re an absense of care - 5 Sat 09 FEB 2019 2.29pm

TOD.0001.0001.0025 Photo attached to email from Tony O’Donnell re an absense of care - 6 Sat 09 FEB 2019 2.29pm

TOD.0001.0001.0026 Photo attached to email from Tony O’Donnell re an absense of care - 7 Sat 09 FEB 2019 2.31pm

TOD.0001.0001.0027 Photo attached to email from Tony O’Donnell re an absense of care - 8 Sat 09 FEB 2019 2.31pm

TOD.0001.0001.0028 Photo attached to email from Tony O’Donnell re an absense of care - 9 Sat 09 FEB 2019 2.31pm

TOD.0001.0001.0029 Photo attached to email from Tony O’Donnell re an absense of care - 10 Sat 09 FEB 2019 2.31pm

TOD.0001.0001.0030 Email from Tony O’Donnell re an absense of care

TOD.0001.0001.0033 Email from Tony O’Donnell re provision of care

TOD.0001.0001.0034 Email from Tony O’Donnell re weekend care and communications

TOD.0001.0001.0035 Email from Tony O’Donnell with reply re weekend care and communications

TOD.0001.0001.0037 Controlling Dementia - Lifestyle & Diet - the MIND diet

TOD.0001.0001.0053 Catalano’s Seafood

TOD.0001.0001.0056 Photo of salmon (1) attached to email from Tony O’Donnell re Fresh! Fresh! Fresh!

TOD.0001.0001.0057 Photo of salmon (2) attached to email from Tony O’Donnell re Fresh! Fresh! Fresh!

TOD.0001.0001.0058 Photo of salmon (3) attached to email from Tony O’Donnell re Fresh! Fresh! Fresh!

TOD.0001.0001.0059 Email from Tony O’Donnell re Fresh! Fresh! Fresh!

AWF.001.00519 Submission to the Royal Commission

RCD.9999.0092.0001 Palliative Care Common Ground Propositions

95

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

RCD.9999.0095.0001 Trigg - Improving the quality of residential care for older people: a study of government approaches in England and Australia

5-8 Mitcham Case Study Tender Bundle

NOL.0001.0001.0042 Email from [Redacted] to Noleen Hausler re- draft agenda and discussion points for meeting with Minister Wyatt.

NOL.0001.0001.0051 Email from Noleen Hausler to Facility Manager Mitcham- 17 January 2016

NOL.0001.0001.0061 Email from Noleen Hausler to Mitcham Facility Manager re - Clarry Hausler UTI

NOL.0001.0001.0067 Email from Noleen Hausler to Mitcham Resident Care re- Clarrys left buttock pressure area

NOL.0001.0001.0070 Email from Noleen Hausler to Mitcham Resident Care re- Incontinence Associated dermatitis.

NOL.0001.0001.0077 Meeting held at Mitchan RCF received 11 January 2016

NOL.0001.0001.0084 Meeting notes ARAS- 9 December 2016

NOL.0001.0001.0086 Mitcham Resident Care Minutes of Meeting 5 January 2015

NOL.0001.0001.0120 ACSAG Meeting Minutes- Extraordinary Resident and Representative Forum- 6 August 2016

NOL.0001.0001.0166 Advocate Support Group

NOL.0001.0001.0194 Minutes for 1st Crisis Kapara Meeting at CF

NOL.0001.0001.0207 Fungal Nails, Isolation, Bruising Issues and Nutrition

NOL.0001.0001.0222 Incontinence acquired dermatitis.pdf

NOL.0001.0001.0241 Photos for Federal Minister for Health and Aged Care - Hon Ken Wyatt

NOL.0001.0001.0244 RIght Ankle Wound

NOL.0001.0001.0295 2. Witness Impact Statement Read in Court

NOL.0001.0001.0298 20. ACCC Issues Aged Care Act Breaches NSW ACCC Final Report 6 Feb 2017

NOL.0001.0001.0315 22. Email Ombudsman My Response 31 May 2017

NOL.0001.0001.0329 27. Intimidation SACAT Sabotage ACSAG ARAS 21 Mar 2016

NOL.0001.0001.0335 29. Intimidation Unprofessional Internal Complaints 21.4.16

NOL.0001.0001.0337 3. Agency Carer Incident Plus CF Response 2 Sept 15

NOL.0001.0001.0340 30. Intimidation Agency RN Non Professional Attitude

NOL.0001.0001.0345 32. ACCC CF RAH My Personal Notes Events Dec 2016

NOL.0001.0001.0395 34. Psychological Support Personal Notes 24.9.15

NOL.0001.0001.0403 38. Dignity Safety Issue Bed unplugged Obstructing toilet

NOL.0001.0002.0001 Footage Lucas Force Poor Hygiene Sneezes.

NOL.0001.0002.0002 Footage Female Agency Staff Serious Risk during feed 1 sept 2015 1700hrs

NOL.0001.0002.0004 Uncut Original Footage Corey Assaulting Dad - Copy

NOL.0001.0002.0005 Dad Restless Post Assault Alone Drinks from cup 9 Sept 2015 - Copy NOL.0001.0002.0006 Video Dads Cognitive Verbal level with me 10 July 2015

NOL.0001.0002.0009 Footage Carer Liz Pt1 eating Dads food 9 Sept 15 5pm

96

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

NOL.0001.0002.0010 Footage Carer Liz Pt 2 eating 9 Sept 2015 5pm

NOL.0001.0002.0011 Footage 2 Carers breach lifter Policy

NOL.0001.0003.0012 Apologies from JAPARA

NOL.0001.0003.0024 ACCC SA Case ID S16 004010 Information

JAH.0001.0003.2493 Mitcham Complaint

JAH.0001.0003.2494 Letter from Noleen Hausler to Rachael Musico complaining of rough conduct by agency nurse

JAH.0001.0003.2496 Letter from Kim Keevers responding to Noleen Hausler’s written complaint

JAH.0001.0003.2500 Re: Mitcham Complaint

JAH.0001.0003.2528 RE: PC- pm shift

JAH.0001.0003.2529 Response To Negative Performance Appraisal

JAH.0001.0003.2534 Re: Update: Mitcham assault case

JAH.0001.0003.2640 FW: Noleen Hausler - Protecting and Assist Clarry’s Investigation

JAH.0001.0003.5150 RE: Noleen Hausler

JAH.0001.0003.5274 Hawsler N.Meeting Oct 21

JAH.0001.0003.5278 Clarry Hausler.doc

JAH.0001.0003.5337 Hausler N meeting 3.11

JAH.0001.0003.5385 Re: Policy re: Noleen Hausler -Video Surveillance in Resident Roo

JAH.0001.0003.5429 RE: Noleen Hausler

JAH.0001.0003.5591 noreply@acsagroup.com.au_2015112 7_123845

JAH.0001.0003.5646 N. Hausler 1.12.15

JAH.0001.0003.5651 N. Hausler 1.12.15

JAH.0001.0003.5663 C Hausler.pdf

NOL.0001.0003.0002 AHPRA Podiatrist Report 8 Aug 2016

NOL.0001.0003.0017 Meeting Rachael Site Manager re CCTV 8 Sept 2015

JAH.0001.0003.2531 FW: Mandatory Report at Mitcham Aged Care 10.09.2015

JAH.0001.0003.2592 RE: Noleen Hausler - Issues / Concerns I wish to put in writing on Clarry’s behalf

JAH.0001.0003.2647 RE: Hausler case

JAH.0001.0003.5271 RE: Noleen Hausler

JAH.0001.0003.5277 Clarry Hausler

JAH.0001.0003.5336 Meeting Noleen Hausler

JAH.0001.0003.5338 RE: Meeting Noleen Hausler

JAH.0001.0003.5396 RE: Noleen Hausler

JAH.0001.0003.5589 Meeting with Noleen Hausler - Tuesday 1 December at 4:00 p.m

JAH.0001.0003.5631 RE: Noleen - Clarry’s re Rooibos Tea

JAH.0001.0003.5650 Meeting summary

JAH.0001.0003.5656 RE: Meeting summary

JAH.0001.0003.5670 RE: Clarence Hausler Sling Lifter Transfers

97

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

JAH.0001.0003.5775 DSS Complaint regarding reportable assault reported 30.11.15

JAH.0001.0003.5776 DSS

JAH.0001.0003.5817 Surveillance Letter

JAH.0001.0003.5818 Noleen Hausler 9.12.15 Covert Recording

JAH.0001.0003.5820 Meeting 3.11.15

JAH.0001.0003.5821 Meeting 21.10.15

JAH.0001.0003.5914 N.Hausler Meeting15.12.15

JAH.0001.0003.6668 FW: Noleen Hausler and Staff Letters

JAH.0001.0003.6670 Statement relating to cards from Noleen Hausler

JAH.0001.0003.6672 Contents of card from Noleen Hausler attached to witness statement

JAH.0001.0003.6673 Cover of card from Noleen Hausler attached to Statement

JAH.0001.0003.6717 Email from Julie Reed to Rachael Musico responding to issues raised by Noleen Hausler

JAH.0001.0003.6909 RE: Various

JAH.0001.0003.7048 RE: Noleen Hausler & On-line petition

JAH.0001.0004.2889 Letter from SACAT notifying MRCF of Guardianship hearing in relation to Clarence Hausler

JAH.0001.0004.2893 FW: Noleen Hausler reply- Support Group and use of Mitcham Facilities

JAH.0001.0004.2962 RE: N Hausler Podiatry Complaint

JAH.0001.0004.3214 Noleen Hausler and SCAT Hearing

JAH.0001.0004.3218 Hausler SACAT hearing 2.3.16

JAH.0001.0004.3219 Notes re N.Hausler providing unsafe personal care- 26.10.15,25.11.15,1.12.15.pdf

JAH.0001.0004.3225 Podiatrist entries, 23.12.15,20.1.16.pdf

JAH.0001.0004.3227 Summary of attachments 2.3.16.docx

JAH.0001.0004.3240 RE: Hausler SACAT hearing 2.3.16

JAH.0001.0004.3365 SACAT Report for C Hausler

JAH.0001.0004.4134 Image of Clarence Hausler in bed appearing to obstruct door entrance

JAH.0001.0004.4135 Image of Clarence Hausler in bed appearing to obstruct door entrance

JAH.0001.0004.4136 Image of Clarence Hausler in bed appearing to obstruct door entrance

JAH.0001.0004.4137 Statement relating to 26 June 2016

JAH.0001.0004.4234 Re: Call Me Please

JAH.0001.0004.4563 Response sent today to Aged Care Commissioner re: Hausler.

JAH.0001.0004.4564 Hausler Clarence Response 10 July 2016.docx

JAH.0001.0004.4783 Review by VIC Office of the Aged Care Commissioner at Mitchem SA

JAH.0001.0004.5123 RE: Mitcham reputation management approach

JAH.0001.0004.6839 RE: Noleen Hausler – Meeting Mon Aug 4th 2.30pm JAH.0001.0004.7184 Meeting Summary

98

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

JAH.0001.0005.3475 FW: Hausler – Staff statements and Petition

JAH.0001.0005.3476 Statement relating to 8 August 2016

JAH.0001.0005.3478 Staff Petition.pdf

JAH.0001.0005.3480 Statement relating to 8 August 2012

JAH.0001.0005.3758 Adelaide this Wednesday 24 August 2016

JAH.0001.0005.3760 08.08 Resident & Representative Meeting Minutes.pdf

JAH.0001.0005.3796 Key Facts re Clarence Hausler and his daughter Noleen Hausler.docx

JAH.0001.0005.3797 Key Facts re Clarence Hausler and his daughter Noleen Hausler.docx

JAH.0001.0005.3824 Email from Julie Reed including updated attachment summarising of events in relation to Clarence Hausler and Noleen Hausle

JAH.0001.0005.3825 Updated Key Facts. Hausler August 2016.docx JAH.0001.0005.4638 Residents and Representatives Meeting Minutes 24.8.16

JAH.0001.0005.4639 Fact Sheet – Visitor Code of Conduct V1.pdf

JAH.0001.0005.5095 Email from Julie Reed attaching additional information

JAH.0001.0005.5096 Request for additional information – Case ID S16-009155 – Clarence Ha….docx

JAH.0001.0005.5148 Email from Julie Reed to Kim Keevers discussing addressing the Aged Care Complaints Commissioner request for additional information

JAH.0001.0005.5151 Request for additional information – Case ID S16-009155 – Clarence Ha….docx

JAH.0001.0005.5160 Email discussing Aged Care Complaints Commissioner request for additional information

JAH.0001.0005.5161 Request for additional information – Case ID S16-009155 – Clarence Ha….docx

JAH.0001.0005.5312 Email from Kim Keevers to Julie Reed responding to Aged Care Complaints Commissioner request for additional information JAH.0001.0005.5917 RE: Confirmation of issues letter – Case ID S17/003042 – Clarence Hausler [Sec=Unclassified]

JAH.0001.0005.5946 FW: Notice of Intention to Issue Directions (NIID) – re Mitcham Residential Care Facility – Clarence Hausler [Sec=Unclassified]

JAH.0001.0005.5948 NIID – Mitcham ACF.pdf

JAH.0001.0005.6005 Re: Notice of Intention to Issue Directions (NIID) – re Mitcham Residential Care Facility – Clarence Hausler [Sec=Unclassified]

JAH.0001.0005.6071 Noleen Hausler – weekly meetings

JAH.0001.0005.6370 Email from Andrew Sudholz to Linda Nicholls, David Blight, Richard England and Larsen Stephenson regarding Mitcham occupancy and complaints

JAH.0001.0005.6481 Email from Andrew Sudholz, Chris Price, Jerome Jordan, Ashley van Winkel regarding meeting with Noleen Hausler

JAH.0001.0005.7156 Letter to John Rau – SA State Attorney General re: Video Surveillance

JAH.0001.0005.7157 Suggested text of letter to SA A-G – December 16 docx.DOCX

99

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

JAH.0001.0005.7388 Incident Mitcham – RE: Noleen – 25.12.16 Camera Installation

JAH.0001.0005.7431 Email from Rachael Musico to Diane Jones recording events

JAH.0001.0005.7433 progress notes.pdf

JAH.0001.0005.7434 Medication Management form of a resident at Mitcham

JAH.0001.0005.7438 1.1.17 time sheets

JAH.0001.0005.7440 Sunday 1.1.17 allocation

JAH.0001.0005.7441 diagram

JAH.0001.0005.7461 Email from Andrew Sudholz to Stuart Woodley and others in relation to Noleen Hausler

JAH.0001.0005.7462 RE: Noleen Hausler matter

JAH.0001.0005.7467 Mitcham & Hausler – Confidential

JAH.0001.0005.7468 Updated key summary in relation to Clarence Hausler

JAH.0001.0006.2660 RE: Complaint Number S17/006439 [Sec=Unclassified]

JAH.0001.0006.2895 RE: Contact list

JAH.0001.0006.2927 Complaint Number S17/006439

JAH.0001.0006.2928 Food and Fluid Charts 12.12.16- 13.12.16.pdf

JAH.0001.0006.2930 Med chart-Oxygen order.pdf

JAH.0001.0006.2932 Meeting summary 13.12.16.docx

JAH.0001.0006.2936 Progress Notes Hausler 10-15 December 2016.pdf

JAH.0001.0006.2950 Response 20.02.17 Clarence Hausler.docx

JAH.0001.0006.3113 S17/003042 (NSW) Hausler – request for further information

JAH.0001.0006.3114 Education Matrix 2015 & 2016.pdf

JAH.0001.0006.3116 Fm – 006 – Orientation of Agency Nursing Personnel Checklist V4.pdf

JAH.0001.0006.3117 Fm – 017 – Onboarding Checklist – Facility Staff V3.pdf

JAH.0001.0006.3118 Master_Wandering Instrusive_interfering Behav HER.doc

JAH.0001.0006.3119 NUR – SOP002 – Nursing – Use of Lifter.docx

JAH.0001.0006.3121 NUR – SOP004 – Nursing – Repositioning Residents in Bed.docx

JAH.0001.0006.3123 Pro – 008 – Wound Management V5.pdf

JAH.0001.0006.3127 Pro – 010 – Nutrition and Hydration V5.pdf

JAH.0001.0006.3132 Pro – 015 – Continence Management V3.pdf

JAH.0001.0006.3142 Staff Handbook – Reviewed March 2016.pdf

JAH.0001.0006.3162 Bed Positioning Care Plan 27.06.16.docx

JAH.0001.0006.3163 Hausler ROD report.pdf

JAH.0001.0006.3165 Letterhead Response S17003042.docx

JAH.0001.0006.3169 Pro – 006 – Resident of the Day Procedure V4.pdf

JAH.0001.0008.0769 RE: Noleen - Reporting Additional Assault 2015

JAH.0001.0008.0770 Compulsory Report – C. Hausler 31 August 2015

JAH.0001.0008.0771 Compulsory Report Mitcham Aged Care

JAH.0001.0008.0772 C. Hausler – Compulsory Report.pdf

JAH.0001.0008.1180 RE: Re N.Hausler

10

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

JAH.0001.0008.1421 Email from Rachael Musico to Julie Reed and Diane Jones regarding call with Public Advocate about Clarence Hausler

JAH.0001.0008.1545 RE: Joan Spehr - Noleen Hausler/John Buckley

JAH.0001.0008.1596 RE: Clarence Hausler Sling Lifter Transfers

JAH.0001.0008.5892 Email banner image

JAH.0004.0001.0461 Policy re: Video Surveillance in Resident Roo

JAH.0100.0001.00049 Noleen Hausler - Meeting Wed 21 2015

NOL.0001.0001.0313 21. Email Ombudsman Final Response to Complaint 17.5.17.docx

RCD.9999.0082.0001 s 63-1AA Aged Care Act 1997 (Cth)

JAH.0001.0003.5387 Email from Rachael Musico to Julie Reed and Diane Jones re meeting with Noleen Hausler on 10 November 2015

JAH.0001.0003.5819 Meeting Notes

JAH.0001.0003.5899 Hausler meeting summary

JAH.0001.0003.5953 N.Hausler meeting

JAH.0001.0003.6782 N.Hausler 12.01.16

JAH.0001.0004.2888 FW: C Hausler SACAT Hearing

JAH.0001.0004.4589 Meeting Wed 13 July 2016 Adair Sudholz My Requests.

JAH.0001.0005.6061 C Hausler Complaint

JAH.0004.0001.1804 Meeting summary 13.12.16

JAH.0016.0001.0010 ACSAG Complaints Procedure

JAH.0114.0001.0068 Pro 009 - Incident Reporting V12.

JAH.0114.0001.0155 Pro – 028 – Whistle Blower Procedure V6 739

JAH.0121.0001.0001 ABL-7063498-1-Sudholz - Summary of Financial Results (Annexure A)

JAH.0121.0001.0003 ABL-7063501-1-Sudholz – list of facilities (Annexure B)

JAH.0121.0001.0004 ABL-7063502-1-Sudholz - Key executives (Annexure C)

JAH.0122.0001.0006 Curriculum Vitae of Diane Jones

JAH.0001.0008.5891 Re: C Hausler

JAH.0004.0001.0460 Any other correspondence re: Surveillance

JAH.0004.0001.1772 Clarence Hausler ongoing document

JAH.0100.0004.00246 Resident Care Plan ADLs

JAH.0001.0003.5900 N.Hausler Meeting15.12.15

JAH.0001.0003.5954 N.Hausler 22.12.15

JAH.0001.0003.6784 RE: N.Hausler 12.01.16

JAH.0001.0004.4128 FW: Noleen Hausler – Bed in corridor + UTI

JAH.0016.0001.0007 Japara Complaints Procedure

JAH.0104.0001.0006 Meeting Held at Mitcham RCF

JAH.0114.0001.0154 Fm - 039 - Compulsory Reporting Fact Sheet

JAH.0114.0001.0160 Pro 009 - Incident Reporting 620

JAH.0121.0001.0005 Sudholz - Vision (Annexure D)

JAH.0122.0001.0010 ACSAG Position Description – Quality Manager

101

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

JAH.0123.0001.0001 Table of reportable assaults in Japara facilities

JAH.0001.0003.5645 N. Hausler 1.12.15

JAH.0001.0003.5662 Clarence Hausler Sling Lifter Transfers

JAH.0001.0003.5913 FW: Hausler meeting summary

JAH.0001.0003.6781 N.Hausler 12.01.16

JAH.0001.0004.4587 RE: meeting with Noleen Hausler

SMA.0001.0001.0004 Lucas, Corey Lyle

NOL.0001.0001.0357 33. ACCC CF RAH Complaint Final Report 2 Feb 2017.docx

JAH.0106.0003.0007 Staff Performance Appraisal Client Evaluation

JAH.0017.0002.0001 2 CAR form recording NH’s complaint.pdf

JAH.0122.0001.0001 1 Position description.pdf

JAH.0013.0001.0148 FW: Attention [Redacted] - Case ID: NF 16/000837 Clarence Hausler

JAH.0013.0001.0149 noreply@acsagroup.com.au_2015091 0_151245.pdf

JAH.0001.0003.2671 Document1.docx

JAH.0001.0005.5069 C Lucas - Suspension 11092015.pdf

JAH.0122.0001.0005 5b Letter to Corey Lucas 22.9.15.pdf

JAH.0017.0003.0007 3 CAR Report Sept 2015.docx

JAH.0017.0003.0023 3 Corrective Action Request Register Oct 2015.doc

JAH.0017.0005.0001 5 Monthly Incident – Accident Report September 2015.docx

JAH.0017.0003.0005 3 CAR Report Oct 2015.docx

JAH.0017.0003.0019 3 Corrective Action Request Register Oct 2015.doc

JAH.0017.0007.0014 10.15 - Monthly Incident Report Register V3.doc

JAH.0122.0001.0009 Notice – Corey Lucas.pdf

JAH.0017.0003.0003 3 CAR Report Nov 2015.docx

JAH.0017.0003.0014 3 Corrective Action Request Register Nov 2015.doc

JAH.0017.0007.0045 11.15- Monthly Incident -Accident Report V2.docx

JAH.0015.0001.0008 Assessment Contact Advice Dec 2015.pdf

JAH.0017.0003.0002 3 CAR Report Dec 2015.docx

JAH.0017.0003.0009 3 Corrective Action Request Register Dec 2015.doc

JAH.0017.0007.0104 Dec 15- Monthly Incident -Accident Report V2.docx

JAH.0001.0004.2941 RE: Noleen Hausler reply - Support Group and use of Mitcham Facilities

JAH.0001.0005.6089 ACCC response december 2015.pdf

JAH.0001.0004.3185 Noleen Hausler - weekly meetings

JAH.0001.0005.6087 Hausler 21.4.16.pdf

JAH.0015.0001.0001 Assessment Advice July 2016.pdf

JAH.0100.0001.00085 Total Care Progress Notes

JAH.0015.0001.0018 Assessment_contact_advice_6002_25 -10-2016.pdf JAH.0015.0001.0019 Assessment_contact_report_6002_25- 10-2016.pdf

JAH.0001.0006.2778 Meeting with Noleen Hausler and [Redacted] David Clinton (ARAS)

10

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

JAH.0001.0005.7532 Hausler AP Finalisation Letter.pdf

JAH.0001.0006.4290 S17 003042 - Finalisation Letter (Provider).pdf

JAH.0015.0001.0002 Assessment Advice July 2017.pdf

JAH.0101.0003.00115 Letter from Aged Care Complaints Commissioner to MRCF regarding complaint in relation to Clarence Hausler

RCD.0010.0001.0095 20181123 Letter to providers (top 100)

SUB.0001.0036.1145 Japara Mitcham | Royal Commission into Aged Care Quality and Safety

JAH.0017.0007.0072 2015 Critical Incident Report Register.doc

SUB.0001.0036.1146 Mitcham Residential Care Facility 1C2C.xlsx

JAH.0014.0001.0001 ABL-7060409-1-External Complaint table exhibit to Rachael Musico Statement . docx JAH.0017.0001.0001 Corrective Action Request Procedure

RCD.9999.0090.0001 Extract of NOL.0001.0002.0001

RCD.9999.0090.0003 Extract of NOL.0001.0002.0004

JAH.0018.0001.0001 Group Quality Manager 10.16.pdf

JAH.0001.0006.2645 RE: Complaint Number S17/006439 [Sec=Unclassified]

JAH.0001.0006.3098 FW: Case Number S17/006439 [Sec=Unclassified]

JAH.0001.0006.3214 RE: Case Number S17/006439 [Sec=Unclassified]

JAH.0001.0006.3423 Attn: [Redacted] S17/006439

JAH.0019.0001.0013 Quality Manager - Position Description 2018

JAH.0020.0001.0001 Itinerary for TL

5-9 WIT.1124.0001.0001 Statement of Noleen Joy Hausler

5-10 WIT.0231.0001.0001 Statement of Rachel Ann Musico

5-12 WIT.0228.0001.0001 Statement of Julie Reed

JAH.0017.0003.0001 3 Bechmarking Report 2015.xls

JAH.0001.0003.5515 2015 Critical Incident Mandatory Reporting Registe.doc

SUB.0001.0036.1147 Mitcham Residential Care Facility.pdf

RCD.9999.0090.0002 Extract of NOL.0001.0002.0002

RCD.9999.0091.0001 Clarry Aug 2003 Paddleboats Mannum SAust

JAH.0018.0001.0004 Stuart Woodley November 18.docx

JAH.0001.0006.2716 FW: Complaint Number S17/006439 [Sec=Unclassified]

JAH.0001.0006.3111 RE: Case Number S17/006439 [Sec=Unclassified]

JAH.0001.0006.3228 RE: Case Number S17/006439 [Sec=Unclassified] Attn: [Redacted]

5-11 WIT.0230.0001.0001 Statement of Diane Jones

103

Appendix 4 Exhibits

Day 27 – 25 June 2019

Exhibit Number Document Number

Exhibit

5-13 WIT.0229.001.0001 Statement of Mark Andrew Sudholz

5-14 WIT.0214.0001.0001 Statement of Jason Burton

5-15 WIT.1139.0001.0001 Statement of EA

5-16 WIT.1138.0001.0001 Statement of Carolyn Gai Jubb

5-18 WIT.1136.0001.0001 Statement of Kate Rice

5-20 RCD.9999.0071.0001 Video Recording of the Evidence for Anthony O’Donnell

Day 28 – 26 June 2019

Exhibit Number Document Number

Exhibit

5-21 WIT.0272.0001.0001 Statement of Stuart Woodley

5-22 WIT.0129.0001.0001 Statement of Gaye Margaret Whitford

5-24 WIT.1127.0001.0001 Statement of Anna Christine Urwin

5-26 WIT.0247.0001.0001 Statement of The Hon. Dr. Kay Christine Lesley Patterson AO

5-28 WIT.0162.0001.0001 Statement of Matthew John Moore

5-30 WIT.0218.0001.0001 Statement of Craig Bowman Sinclair

Day 29 – 27 June 2019 Exhibit Number Document

Number

Exhibit

5-31 Alkira Gardens Tender Bundle

SLC.0001.0002.3588 St George Discharge Referral Note

SHA.0002.0001.0002 RUD-2 - Letter from Department of Health regarding Vincent Paranthoiene’s ACAT Assessment

SLC.0001.0002.3762 Resident Respite Agreement

SLC.0001.0002.3654 Nursing Progress Notes

SLC.0001.0002.3400 Body Map

SLC.0001.0002.3396 Pain Assessment

SLC.0001.0002.3418 Pain Management Chart

SLC.0001.0002.3656 Nursing Progress Notes

SHA.0002.0001.0001 RUD-1 - Photo of Vincent Paranthoiene

5-17 WIT.1137.0001.0001 Statement of Kevin Charles Chester

5-19 WIT.1135.0001.0001 Statement of Bryan David Lipmann

5-23 WIT.1131.001.0001 Statement of Emma-Kaitlin Murphy

5-25 WIT.1130.0001.0001 Statement of Patti Annie Houston

5-27 WIT.0210.0001.0001 Statement of Dale Allyson Fisher

5-29 WIT.0158.0002.0001 Statement of John Michael Rungie

10

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

SLC.0001.0002.3658 Nursing Progress Notes

SLC.0001.0002.3660 Nursing Progress Notes

SLC.0001.0002.3807 Permanent Resident Agreement

SLC.0001.0002.3615 Medication Chart

SLC.0001.0002.3619 Medication Chart

SLC.0001.0002.3390 Care Plan - Complex Health Care

SLC.0001.0002.3637 Care Plan - Pain Management

SLC.0001.0002.3662 Nursing Progress Notes

SLC.0001.0002.3416 Pain Management Chart

SLC.0001.0002.3664 Nursing Progress Notes

SLC.0001.0002.3666 Nursing Progress Notes

SHA.0002.0001.0004 RUD-3 - Photo of Paranthoiene’s lump on ribs

SLC.0001.0002.3395 Pain Assessment

SHA.0002.0001.0005 RUD-4 - St George Discharge Referral Note

SLC.0001.0002.3574 St George Discharge Referral Note

SLC.0001.0002.3668 Nursing Progress Notes

SLC.0001.0002.3414 Pain Management Chart

SLC.0001.0002.3617 Medication Chart

SLC.0001.0001.3739 Cohen Consultation Notes

SLC.0001.0002.3670 Nursing Progress Notes

SLC.0001.0002.3531 Wound Care Chart - Part A: Wound Assessment & Description

SLC.0001.0002.3613 Medication Chart

SLC.0001.0002.3672 Nursing Progress Notes

SLC.0001.0001.5308 Cohen Consultation Notes

SLC.0001.0002.3534 Wound Care Chart - Part D: Progressive Wound Evaluation

SLC.0001.0002.3089 Notice of Decision to Impose Sanctions

SLC.0001.0002.3258 Review Audit Assessment Report

SHA.0002.0001.0013 RUD-5 - Letter from Department of Health to Ruddock

SLC.0001.0002.3674 Nursing Progress Notes

SLC.0001.0007.0002 Email from Alkira Gardens to Department of Health attaching Training Proposal and Plan

SLC.0001.0007.0003 Training Proposal and Plan

SLC.0001.0005.2937 Email from Alkira Gardens to the Australian Aged Care Quality Agency attaching Training Proposal and Plan, Continuous Improvement Plan and Covering Letter

SLC.0001.0001.3737 Email from Cohen to Alkira Gardens attaching Consultation Notes

SLC.0001.0001.5307 Email from Cohen to Alkira Gardens attaching Consultation Notes

105

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

SLC.0001.0005.2971 Training Proposal and Plan

SLC.0001.0005.2987 Covering Letter from Alkira Gardens to the Australian Aged Care Quality Agency

SLC.0001.0005.2938 Continuous Improvement Plan

SLC.0001.0002.3310 Australian Aged Care Quality Agency Audit Report

SLC.0001.0001.3786 Australian Aged Care Quality Agency Consideration of Serious Risk Report

SLC.0001.0001.1677 Internal Alkira Gardens email

SLC.0001.0001.1678 Admission Form

SLC.0001.0001.4643 Covering Letter from Alkira Gardens to the Australian Aged Care Quality Agency

SLC.0001.0001.4637 Response from Alkira Gardens to the Consideration of Serious Risk Report

SLC.0001.0001.3752 Email from the Australian Aged Care Quality Agency to Alkira Gardens attaching Serious Risk Report

SLC.0001.0001.3754 Australian Aged Care Quality Agency Serious Risk Report

SLC.0001.0001.3767 Australian Aged Care Quality Agency Serious Risk Report - Certificate for Disclosure of Protected Information

SLC.0001.0005.0066 Email from Department of Health to Alkira Gardens attaching Notice of Non-Compliance

SLC.0001.0005.0067 Department of Health Notice of Non-Compliance

SLC.0001.0003.2081 Email from Department of Health to Alkira Gardens attaching Notice to Remedy Non-Compliance

SLC.0001.0003.2082 Department of Health Notice to Remedy Non-Compliance

SLC.0001.0003.2384 Email from Alkira Gardens to Department of Health attaching Undertaking to Remedy Non-Compliance

SLC.0001.0003.2385 Undertaking to Remedy Non-Compliance

SLC.0001.0003.2089 Email from Department of Health to Alkira Gardens attaching No Further Action Letter

SLC.0001.0003.2090 Department of Health No Further Action Letter

SLC.0001.0002.3397 Pain Assessment in Advanced Dementia (PAINAD)

SLC.0001.0002.3626 Resident Interim Care Plan

SLC.0001.0002.3623 Medication Chart

SLC.0001.0002.3621 Medication Chart

SLC.0001.0002.3566 Medical Notes

SLC.0001.0001.3784 Internal Alkira Gardens email containing email from the Australian Aged Care Quality Agency to Alkira Gardens attaching Consideration of Serious Risk Report dated 7 November 2017

SLC.0001.0001.4636 Email from Alkira Gardens to the Australian Aged Care Quality Agency attaching Response to Consideration of Serious Risk Report and Covering Letter

10

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

SLC.0001.0003.2060 Pain Management Chart

SLC.0001.0002.3608 Letter from Mobile X-Ray Services to GP

SLC.0001.0002.3386 Medication Administration Assessment

SLC.0001.0002.3634 Care Plan - Skin Integrity Maintenance

SLC.0001.0002.3567 Medical Notes

SLC.0001.0002.3598 CT Scan Report

SLC.0001.0002.3420 Weight Management Strategies Checklist (For Weight Loss)

SLC.0001.0002.3600 Dietary Review

SLC.0001.0002.3422 Clinical Protocol - Return from Hospital Leave

SLC.0001.0002.3582 Residential Aged Care Facility Transfer / Discharge Summary

SLC.0001.0002.3571 Discharge Summary

SLC.0001.0002.3546 Nursing Progress Notes

SLC.0001.0002.3487 Repositioning Record

SLC.0001.0002.3568 Medical Notes

SLC.0001.0002.3485 Repositioning Record

SLC.0001.0002.3355 Care Directive

SLC.0001.0002.3528 Clinical Protocol - Norton Score Result and Pressure Area / Sore

SLC.0001.0001.5326 Email from Cohen to the GP

SLC.0001.0002.3533 Photo of Sacrum (Tailbone) as of 1/10/17

SLC.0001.0002.3483 Repositioning Record

SLC.0001.0002.3481 Repositioning Record

SLC.0001.0003.2381 Letter from Alkira Gardens to Department of Health regarding Appointment of Administrator and Training

SLC.0001.0005.8187 Email from Alkira Gardens to Department of Health attaching Letter regarding Appointment of Administrator

SLC.0001.0005.8188 Letter from Alkira Gardens to Department of Health regarding Appointment of Administrator

SLC.0001.0003.2481 Email chain between Alkira Gardens and Department of Health regarding Apppointment of Administrator and Advisor

SLC.0001.0002.3479 Repositioning Record

SLC.0001.0004.0005 Email from Alkira Gardens to Department of Health attaching Corporate Governance Action Plan, Re-Consideration to Revoke, Continuous Improvement Plan and Covering Letter

SLC.0001.0004.0006 Corporate Governance Action Plan

SLC.0001.0004.0008 Re-Consideration to Revoke

SLC.0001.0004.0029 Continuous Improvement Plan

SLC.0001.0003.2380 Email from Alkira Gardens to Department of Health attaching Letter regarding Appointment of Administrator and Training

107

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

SLC.0001.0004.0028 Covering Letter from Alkira Gardens to the Department of Health

LCM.0002.0001.0001 JBC-3 - Joshua Cohen - Curriculum Vitae

SLC.0001.0002.3554 Accident/Incident Report

SLC.0001.0002.3555 Post Fall Screening

SLC.0001.0002.3541 Accident/Incident Report

SLC.0001.0002.3544 Post Fall Screening

SLC.0001.0002.3550 Clinical Protocol - Post Fall/Accident/Incident

SLC.0001.0002.3548 Accident/Incident Report

SLC.0001.0002.3537 Accident/Incident Report

SLC.0001.0002.3540 Post Fall Screening

SLC.0001.0009.0005 Falls Risk Assessment Tool

SLC.0001.0002.3375 Personal Hygiene Assessment

SLC.0001.0002.3440 Sight Chart

SLC.0001.0002.3445 Sight Chart

SLC.0001.0002.3447 Sight Chart

SLC.0001.0002.3450 Sight Chart

SLC.0001.0002.3453 Sight Chart

SLC.0001.0002.3455 Sight Chart

SLC.0001.0002.3459 Sight Chart

LCM.0002.0002.0001 JBC-4 - Joshua Cohen - ACCC Progress Notes

SLC.0001.0002.3556 Clinical Protocol - Post Fall/Accident/Incident

SLC.0001.0002.3542 Accident/Incident Report

SLC.0001.0002.3543 Clinical Protocol - Post Fall/Accident/Incident

SLC.0001.0002.3549 Accident/Incident Report

SLC.0001.0002.3552 Post Fall Screening

SLC.0001.0002.3547 Accident/Incident Report

SLC.0001.0002.3538 Clinical Protocol - Post Fall/Accident/Incident

SLC.0001.0002.3553 Neurological Observations Chart

SLC.0001.0009.0009 Frequent Observations Chart

SLC.0001.0002.3413 Norton Score

SLC.0001.0002.3443 Sight Chart

SLC.0001.0002.3446 Sight Chart

SLC.0001.0002.3448 Sight Chart

SLC.0001.0002.3452 Sight Chart

SLC.0001.0002.3454 Sight Chart

SLC.0001.0002.3457 Sight Chart

10

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

SLC.0001.0002.3460 Sight Chart

SLC.0001.0002.3462 Sight Chart

SLC.0001.0002.3466 Sight Chart

SLC.0001.0002.3470 Sight Chart

SLC.0001.0002.3474 Sight Chart

SLC.0001.0002.3477 Sight Chart

SLC.0001.0002.3545 Wound Care

SLC.0001.0002.3630 Physiotherapy Assessment

SLC.0001.0002.3651 Care Plan - Personal Hygiene

SLC.0001.0008.0003 Email from Ruddock to Leong

SLC.0001.0009.0085 Complaints Resolution Policy

SLC.0001.0009.0210 Nutrition and Hydration Policy

SLC.0001.0009.0216 Palliative Care Policy

SLC.0001.0009.0228 Standard Wound Management

SLC.0001.0010.0002 Pain Management Policy

5-32 WIT.1132.0001.0001 Statement of Shannon Maree Ruddock

5-34 WIT.0225.0001.0001 Statement of Joshua Bedford Cohen

5-36 WIT.0244.0001.0001 Statement of John Leong

5-38 WIT.0159.0001.0001 Statement of Jane Fischer

SLC.0001.0002.3464 Sight Chart

SLC.0001.0002.3468 Sight Chart

SLC.0001.0002.3472 Sight Chart

SLC.0001.0002.3476 Sight Chart

SLC.0001.0002.3506 Personal Hygiene Record

SLC.0001.0002.3629 Physiotherapy Care Plan

SLC.0001.0002.3642 Care Plan - Nutrition and Hydration

SLC.0001.0008.0001 Email chain between Ruddock, Leong and Le

SLC.0001.0008.0004 Email chain between Ruddock, Leong and Le

SLC.0001.0009.0087 Family Conference Template Form

SLC.0001.0009.0212 Maintenance of Skin Integrity Policy

SLC.0001.0009.0220 Improvement Log

SLC.0001.0010.0001 Clinical Protocol - Pain Management Guideline

SLC.0001.0002.3518 Frequent Observations Monitoring Record

5-33 WIT.0179.0001.0001 Statement of Joshua Bedford Cohen

5-35 WIT.0244.0002.0001 Supplementary Statement of John Leong

5-37 WIT.0173.0001.0001 Statement of Jennifer Joy Tieman

5-39 WIT.0187.0001.0001 Statement of Elizabeth Nancy Reymond

109

Appendix 4 Exhibits

Day 30 – 28 June 2019

Exhibit Number Document Number

Exhibit

5-40 WIT.0156.0001.0001 Statement of Lisa Jane Trigg

Tab 67 AWF.001.00519 Submission of Bernard Cooney to the Royal Commission

5-41 WIT.0277.0001.0001 Statement of Kimberley Keevers 5-42 WIT.0276.0001.0001 Statement of TL

Darwin - Cairns

Day 31 – 8 July 2019

Exhibit Document

Exhibit

Number Number

6-1 Darwin General Tender Bundle

KSB.0001.0002.0001 Photograph - Dad

KSB.0001.0001.0002_E Photograph – Dad on the floor

KSB.0001.0001.0003_E Photograph – urine stained pillow

KSB.0001.0001.0004_E Photograph – Dad’s fingernails

LTW.0001.0001.0001 Example employee training and competency documents for catering and hospitality staff

LTW.0001.0001.0008 Example food safety training course modules, email containing links to government resources on the 2019 Food Standards Australia and New Zealand and NSW food authority guidelines

LTW.0001.0001.0081 Example of a dietician’s final menu review, as received by Mrs. Twyord/her employer and prepared following a consultation and feedback process

LTW.0001.0001.0112 Supplier Photograph and product description – example of the specialty crockery (1)

LTW.0001.0001.0113 Supplier Photograph and product description – example of the specialty crockery (2)

LBA.0001.0001.0038 Photograph of Christine Weightman as a nurse

LBA.0001.0001.0017 Photograph of injuries from earlier fall

LBA.0001.0001.0005 Photograph of continence aid

LBA.0001.0001.0007 Photograph of water container

LBA.0001.0001.0004 Photograph of pressure injury

LBA.0001.0001.0022 Photograph from CCTV footage

LBA.0001.0001.0024 Photograph from CCTV footage

LBA.0001.0001.0009 Photograph of Christine Weightman

LBA.0001.0001.0003 Photograph of Christine Weightman in aged care

LBA.0001.0001.0018 Photograph of injuries from earlier fall

LBA.0001.0001.0008 Photograph of Christine Weightman’s broken leg

LBA.0001.0001.0006 Photograph of Christine Weightman

LBA.0001.0001.0014 Photograph of Christine Weightman on Christmas day 2018

LBA.0001.0001.0023 Photograph from CCTV footage

LBA.0001.0001.0025 Photograph from CCTV footage

11

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

LBA.0001.0001.0026 Photograph from CCTV footage

LBA.0001.0001.0028 Photograph from CCTV footage

LBA.0001.0001.0034 Photograph from CCTV footage

LBA.0001.0001.0032 Photograph from CCTV footage

LBA.0001.0001.0020 Photograph from CCTV footage

LBA.0001.0001.0013 Photograph of Christine Weightman in aged care

JAB.0001.0001.0057 You are never ‘just’ an aged care nurse: A personal story, The Hive

SMG.0001.0001.0001 Nurse practitioner standards for practice – Effective from 1 January 2014

SMG.0001.0002.0001 Nurse Practitioner – Acute and Supportive Care

SMG.0001.0002.0011 Nurse Practitioner – Primary Care

SMG.0001.0002.0016 Diagnostic Ultrasonography Available to Private Sector Nurse Practitioners

SMG.0001.0002.0017 Fact Sheet: Nurse practitioner category notation (Victoria)

JML.0001.0001.0001 Photograph – Dad prior to entering Darwin Facility

JML.0001.0001.0003 Photograph – Dad after medication

JML.0001.0001.0005 Hospital Transfer Form

CSH.0001.0001.0032 Two-Hourly Repositioning for Prevention of Pressure Ulcers in the Elderly: Patient Safety or Elder Abuse

CSH.0001.0001.0094 Photograph – non healing ulcer

NTH.0001.0003.0001 Q8 Attachment A - excerpt NT Psychogeriatric Service Review Report

NTH.0001.0003.0004 Q19 Attachment A - Discharge Summary TEHS Hospitals Procedure

NTH.0001.0003.0022 Q22 Attachment A - ACAT Performance Report June 2018

NTH.0001.0003.0077 Q22 Attachment B - ACAT Performance Report Nov 2018

LBA.0001.0001.0027 Photograph from CCTV footage

LBA.0001.0001.0029 Photograph from CCTV footage

LBA.0001.0001.0031 Photograph from CCTV footage

LBA.0001.0001.0033 Photograph from CCTV footage

LBA.0001.0001.0021 Photograph from CCTV footage

JAB.0001.0001.0001 Wrestling with Dementia: A Report for Alzheimer’s Australia, Paper 34 June 2013

SMG.0001.0002.0008 Nurse Practitioner – Aged Care

SMG.0001.0002.0015 Diagnostic Radiography Available to Private Sector Nurse Practitioners

JML.0001.0001.0002 Photograph – Dad prior to entering Darwin Facility

JML.0001.0001.0004 Photograph – Dad after medication

CSH.0001.0001.0001 Catherine Sharp CV

CSH.0001.0001.0093 Photograph – skin tear

CSH.0001.0001.0095 Photograph – tissue death

111

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

NTH.0001.0003.0093 Q22 Attachment C - ACAT Performance Report May 2019

NTH.0001.0003.0069 Q25 Attachment B - RACF Placement TEHS Policy

NTH.0001.0003.0075 Q25 Attachment D - RACF Placement TEHS Pamphlet

ACO.0001.0001.0001 Central Australian Aboriginal Congress Aboriginal Corporation Annual Report for 2017/2018

ACO.0001.0001.0079 Map of Central Australian Aboriginal Congress service area

LNA.0001.0001.0001 LNAC submission to the Royal Commission into Aged Care Quality and Safety

NCH.0001.0001.0001 Photograph – Cinema

NCH.0001.0001.0009 Photograph - Hairdressers

NCH.0001.0001.0015 Photograph - Dining

MBF.0001.0001.0001 Summary Literature review conducted by MBF highlighting the impact of aging on the enjoyment of food and the consequences on consumption and ultimately malnutrition

DAA.0001.0001.0001 Scoping Project Literature Review (2012)

DAA.0001.0001.0046 Meals on Wheels: Who’s referring and what’s on the menu? (2018)

DAA.0001.0001.0054 Individualized Nutrition Approaches for Older Adults: Long- Term Care, Post-Acute Care, and Other Settings (2018)

DAA.0001.0001.0066 Menu Planning in Residential Aged Care – The Level of Choice and Quality of Planning of Meals Available to Residents (2015)

DAA.0001.0001.0079 Malnutrition in older Australians (2019)

RCD.9999.0096.0270 Wounds Australia Standards for Wound Prevention and Management (2016, 3rd edn)

RCD.9999.0096.0336 Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury (2012)

RCD.9999.0096.0460 Norton Pressure Sore Risk-Assessment Scale Scoring System

RCD.9999.0096.0463 Braden Scale for Predicting Pressure Sore Risk

ALE.0001.0002.0001 Medicare Benefits Schedule

NTH.0001.0003.0040 Q25 Attachment A - PATS Guidelines

NTH.0001.0003.0071 Q25 Attachment C - RACF Placement TEHS Procedure

RCD.999.0093.0001 Mildred Numamurdirdi video

LNA.0001.0001.0141 Map of Larrakia Nation service area

NCH.0001.0001.0005 Photograph - NewDirection

NCH.0001.0001.0010 Photograph - Shopping

RCD.9999.0094.0089 Southcare Geriatric Flying Squad: an innovative Australian model providing acute care in residential aged care facilities

MBF.0001.0001.0004 Literature review conducted by MBF highlighting the impact of aging on the enjoyment of food and the consequences on consumption and ultimately malnutrition

DAA.0001.0001.0030 BMI and all-cause mortality in older adults: a meta-analysis

RCD.9999.0096.0461 Adapted Waterlow Pressure Area Risk Assessment Chart

RCD.9999.0096.0465 STAR Skin Tear Classification System

11

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

ALE.0001.0001.0001 Example of missed care – dentures

ALE.0001.0001.0002 Example of missed care – natural teeth

ALE.0001.0001.0003 Building Better Oral Health Communities Project Summary

ALE.0001.0001.0011 National Screening and Assessment Form (NSAF) Comprehensive Assessment

ALE.0001.0001.0058 Media Release – Australia’s First Dental Plan for Nursing Homes (1 March 2009)

RCD.9999.0047.0001 Better Oral Health in Residential Care Final Report

JOS.0001.0001.0001 Continence Tools for Residential Aged Care: An Education Guide

JOS.0001.0001.0033 Continence Assessment Form and Care Plan

JOS.0001.0001.0041 Continence Review Form

JOS.0001.0001.0048 Learning to accept incontinence and continence care in residential aged care facilities: Family members’ experiences (2016)

JOS.0001.0001.0056 Legal opinion re: validity of continence care policies and practices in long term care homes (2007)

JOS.0001.0001.0085 Monthly Bowel Chart

JOS.0001.0001.0086 Reframing continence care in care-dependence (2017)

JOS.0001.0001.0093 Fear and overprotection in Australian residential aged care facilities

JOS.0001.0001.0121 Three Day Bladder Chart

JOS.0001.0003.0001 GEN Aged Care Data 2015-16: People’s care needs in aged care (2017)

JOS.0001.0003.0003 A conceptual model of the risk of elder abuse posed by incontinence and care dependence (2017)

JOS.0001.0004.0001 A suite of evidence-based continence assessment tools for residential aged care (2011)

JOS.0001.0005.0253 Incontinence in Australia (2013)

JOS.0001.0005.0417 The Resident Assessment Instrument – Minimum Data Set 2.0 quality indicators (2010)

RCD.9999.0096.0001 SARRAH report on the economic impact of allied health interventions

RCD.9999.0096.0113 Strategies for increasing allied health recruitment and retention in rural Australia

RCD.9999.0096.0165 Report from the Allied Health Reference Group, 2018

RCD.9999.0094.0031 A systematic review of instruments for measuring outcomes in economic evaluation within aged care

RCD.9999.0094.0018 Economic evaluations in community aged care: a systematic review

JOS.0001.0001.0040 Continence Management flow chart

JOS.0001.0001.0042 Continence Screening Form

JOS.0001.0001.0101 Seven Day Bowel Chart

JOS.0001.0002.0001 The economic impact of incontinence in Australia (2011)

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

113

RCD.9999.0094.0073 Not just about costs: the role of health economics in facilitating decision making in aged care

RCD.9999.0094.0017 A good life: developing a new quality of life instrument within older Australians for economic evaluation in aged care

RCD.9999.0097.0001 Developing a new quality of life

SIU.0001.0001.0001 Photographs of food

RCD.9999.0102.0002 Annexure 2 – Relevant experience of Dr Sarah Giles

RCD.9999.0102.0004 Annexure 4 – Continuum of Cultural Competence

RCD.9999.0103.0001 Antipsychotic medicines dispensed before and after entering residential aged care: Preliminary report and findings from the National Historic Cohort of the Registry of Older South Australians

RCD.9999.0098.0001 Antidepressants and benzodiazepines medicines dispensed before and after entering residential aged care: Preliminary report and findings from the National Historic Cohort of the Registry of Older South Australians

RCD.9999.0100.0001 Medicare Benefits Schedule Review Taskforce: Final Report of the Allied Health Reference Group – SARRAH Consultation Response

RCD.9999.0100.0012 Discussion Paper for Consultation: Rural Allied Health Quality, Access and Distribution, Options for Commonwealth Government Policy Reform and Investment

RCD.9999.0111.0001 Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers

RCD.9999.0113.0001 Interventions for preventing falls in older people in care facilities and hospitals (Review)

RCD.9999.0114.0001 ACITC_TechnologyRoadmap 2017

RCD.9999.0114.0054 Diagram 1 Summarised view of generic medication workflow in RACFs

RCD.9999.0114.0055 Diagram 2 Workflow changes in eNRMC Trial

RCD.9999.0114.0056 National Health (Electronic National Residential Medication Chart Trial) Special Arrangement 2018

RCD.9999.0114.0071 NRMC-phased-implementation-evaluation-report

RCD.9999.0118.0001 Fifth Community Pharmacy Agreement

RCD.9999.0119.0001 Extract of MBS – Item 903

RCD.9999.0115.0001 The effectiveness of a twice-daily skin-moisturising regimen for reducing the incidence of skin tears

RCD.9999.0097.0007 Does one size fit all? Assessing the preferences of older

RCD.9999.0102.0001 Annexure 1 - Former positions held by Olga Haven

RCD.9999.0102.0003 Annexure 3 – Map of Major Aboriginal Languages in the NT

CSH.0001.0001.0022 Estimating the risk of pressure ulcer development: is it truly evidence based?

RCD.9999.0114.0120 US and Canadian Quality Indicators

RCD.9999.0118.0037 Sixth Community Pharmacy Agreement

RCD.9999.0119.0004 FAQ – Ensuring sustainability and delivering efficiencies

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

114

Exhibit Document

Exhibit

Number Number

RCD.9999.0116.0001 Cost-effectiveness of multidisciplinary wound care in nursing homes: a pseudo-randomized pragmatic cluster trial

RCD.9999.0112.0001 Making a Difference: The Human Service Sector of the Northern Territory

SIU.0001.0002.0001 What does it cost to feed aged care residents in Australia? (2018)

MBF.0001.0002.0001 The role of dietitians in residential aged care: How do cooks and chefs perceive their contribution? (2018)

6-3 WIT.0254.0001.0001 Statement of Sarah Louise Brown

6-5 WIT.0265.0001.0001 Statement of Ms Donna Ah Chee concurred in by Dr Boffa

6-7 WIT.0235.0001.0001 Statement of Michelle Mckay

Day 32 – 9 July 2019

Exhibit Document

Exhibit

Number Number

6-8 William Beach Gardens Tender Bundle

IRT.0001.0001.0184 IRT Memo re: Shirley Fowler

IRT.0001.0001.0350 Complaints/Comments Issue Summary Reference 2017-03

IRT.0001.0001.0478 Australian Aged Care Quality Agency Self-Assessment Tool - IRT William Beach Gardens

IRT.0001.0001.0645 5.0 Pain Assessment-Management Plan Review WBG April17 (3).pdf

IRT.0001.0001.0662 Medication Administration Assessment Report WBG

IRT.0001.0002.0010 Fowler Salesforce - Enterprise Edition Records

IRT.0001.0002.0039 Email from L Fowler to K Perry titled “Lactose free supplies” (dated 20.10.2017)

IRT.0001.0002.0048 Email chain between L Fowler and K Perry titled “Lactose free supplies” (dated 20.10.2017 - 21.10.2017)

IRT.0001.0002.0058 Email chain between L Fowler and K Perry titled “Re RE Shirley Fowler” (Dated 29.6.2017 - 3.7.2017)

IRT.0001.0002.0066 Email chain between L Fowler and K Perry titled “RE Shirley Fowler” (dated 7.8.2017 - 8.8.2017)

IRT.0001.0002.0069 Email chain between L Fowler and K Perry titled “RE System failure” (dated 12.4.2018)

IRT.0001.0002.0075 Email chain between L Fowler and K Perry titled “RE {EXT} Lactose free meals” (dated 20.2.2019 - 22.2.2019)

IRT.0001.0002.0087 Email chain between L Fowler and K Perry titled “RE {EXT} Pureed meals” (dated 6.2.2019 - 7.2.2019)

IRT.0001.0002.0107 Email from L Fowler to K Perry titled “Shirley Fowler” (dated 9.3.2018)

6-2 WIT.0233.0001.0001 Statement of Dr Meredith Hansen-Knarhoi

6-4 WIT.0264.0001.0001 Statement of Kim Maree Mcrae

6-6 WIT.0263.0001.0001 Statement of Olga Havnen concurred in by Dr Giles

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

115

IRT.0001.0002.0108 Email from M Hurdling to K Perry and L Fowler titled “Summary - Meeting with Lyndall Fowler” (dated 8.3.2019)

IRT.0001.0002.0111 Email from L Fowler to K Perry titled “{EXT} Lactose free meals” (dated 20.2.2019)

IRT.0001.0002.0130 Email titled “{EXT} Thanks for Lactose Free Foods” (dated 5.3.2019)

IRT.0001.0002.0136 Dental Consent Form 11.2018.pdf

IRT.0001.0002.0137 Dental Pain 29.11.2018.pdf

IRT.0001.0002.0142 Dental Visit 28.11.2018.pdf

IRT.0001.0002.0154 Email from L Fowler to Dapto Healthcare forwarded to K Taylor titled “Fwd_ ATT Dr Robert Bird” (dated 05.04.2019)

IRT.0001.0002.0166 Email Fwd_ End of Life Plan for Shirley Fowler - please fwd. to Sam 22.05.2017-2.pdf

IRT.0001.0002.0173 Email Fwd_ Foot protectors 19.03.2018.pdf

IRT.0001.0002.0182 Email Fwd_ Lyndal Fowler 23.05.2017.pdf

IRT.0001.0002.0186 Email Fwd_ Maggie’s mission_ why we need to give food more thought 30.01.2017.pdf

IRT.0001.0002.0190 Nebo menu.xlsx

IRT.0001.0002.0204 Email between L Fowler and K Taylor Fwd_ Palliative Care 05.04.2019.pdf

IRT.0001.0002.0217 Email chain between K Taylor and L Fowler titled “Fwd_ SD Fowler” (dated 18.3.2018 - 20.03.2018)

IRT.0001.0002.0220 Email Fwd_ SD Fowler 21.03.2018-2.pdf

IRT.0001.0002.0225 Email chain between K Taylor and L Fowler titled “Fwd_ SD Fowler” (dated 18.3.2018 - 21.03.2018)

IRT.0001.0002.0240 Email chain between K Taylor and L Fowler titled “Fwd_ SDF scalp care” (dated 7.8.2018 - 08.08.2018)

IRT.0001.0002.0242 Email Fwd_ Shirley Fowler 04.05.2018.pdf

IRT.0001.0002.0246 Email Fwd_ Shirley Fowler 08.01.2018-2.pdf

IRT.0001.0002.0251 Email Fwd_ Shirley Fowler 10.10.2018.pdf

IRT.0001.0002.0261 Email between K Taylor and L Fowler titled “Fwd_ Shirley Fowler” (dated 29.01.2017)

IRT.0001.0002.0263 Email titled “Fwd_ Shirley Fowler eye” (dated 12.10.2018)

IRT.0001.0002.0318 Positioning Options - 06.02.2019.pdf

IRT.0001.0002.0351 Lifestyle Activity Record - 1 July 2016 - 1 January 2019

IRT.0001.0002.0389 Email from K Perry to L Fowler titled “Follow up”

IRT.0001.0002.0392 Email from L Fowler to A Creed titled “FW: Dying with dementia”

IRT.0001.0002.0397 Email from L Fowler to S Fisher titled “Fwd: Shirley Fowler”

IRT.0001.0002.0413 Email from L Fowler to S Fisher titled “RE: Follow up”

IRT.0001.0002.0419 Email Re: SD Fowler

IRT.0001.0002.0430 Email RE: SD Fowler

IRT.0001.0002.0437 Email from K Perry to L Fowler titled “RE: Shirley Fowler”

IRT.0001.0002.0466 Email from K Perry to L Fowler titled “Shirley Fowler”

IRT.0001.0002.0470 Email Shirley Fowler

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

116

Exhibit Document

Exhibit

Number Number

IRT.0001.0002.0474 Email from L Fowler to K Perry titled “Shirley Fowler”

IRT.0001.0002.0483 COMMENTS AND COMPLAINTS CENTRAL REGISTER 2018.xls

IRT.0001.0002.0549 Email from K Taylor to L Fowler titled “RE: Shirley Fowler”

IRT.0001.0002.0550 Email chain titled “RE: {EXT} Shirley Fowler” (4.3.2019 - 5.3.2019)

IRT.0001.0002.0558 Email chain titled “Re: {EXT} Shirley Fowler” (dated 4.3.2019 - 5.3.2019)

IRT.0001.0002.0569 Primary Medication Charts 2016-2018

IRT.0001.0002.0583 Short Course Medication Interim Signing Sheets 2017-2018

IRT.0001.0002.0591 Acute Care Needs _ Nursing Care Plan Shirley Fowler 13th December 2016.rtf

IRT.0001.0002.0598 Acute Care Needs _ Nursing Care Plan Shirley Fowler 18th October 2016.rtf

IRT.0001.0002.0602 Acute Care Needs _ Nursing Care Plan Shirley Fowler 29th July 2016.rtf

IRT.0001.0002.0608 Airways Breathing Circulation Assessment 17 August 2018.rtf

IRT.0001.0002.0630 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 12th October 2016.rtf

IRT.0001.0002.0636 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 15th June 2017.rtf

IRT.0001.0002.0643 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 16th April 2018.rtf

IRT.0001.0002.0650 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 17th June 2017.rtf

IRT.0001.0002.0657 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 17th March 2017.rtf

IRT.0001.0002.0664 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 18th August 2017.rtf

IRT.0001.0002.0671 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 18th October 2016.rtf

IRT.0001.0002.0678 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 1st August 2017.rtf

IRT.0001.0002.0685 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 1st December 2017.rtf

IRT.0001.0002.0692 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 21st April 2017.rtf

IRT.0001.0002.0699 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 28th December 2017.rtf

IRT.0001.0002.0706 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 29th December 2017 2.rtf

IRT.0001.0002.0713 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 29th December 2017.rtf

IRT.0001.0002.0720 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 29th March 2017.rtf

IRT.0001.0002.0727 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 2nd April 2018.rtf

117

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

IRT.0001.0002.0735 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 2nd December 2016.rtf

IRT.0001.0002.0742 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 2nd July 2016.rtf

IRT.0001.0002.0748 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 31st July 2017.rtf

IRT.0001.0002.0755 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 3rd April 2018.rtf

IRT.0001.0002.0763 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 3rd July 2016.rtf

IRT.0001.0002.0769 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 4th December 2017.rtf

IRT.0001.0002.0776 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 4th July 2016.rtf

IRT.0001.0002.0782 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 4th October 2016. 2rtf.rtf

IRT.0001.0002.0788 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 4th October 2016.rtf

IRT.0001.0002.0794 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 5th December 2016.rtf

IRT.0001.0002.0801 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 5th June 2017.rtf

IRT.0001.0002.0808 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 6th October 2016.rtf

IRT.0001.0002.0814 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 7th April 2017.rtf

IRT.0001.0002.0821 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 7th April 2018.rtf

IRT.0001.0002.0829 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 7th March 2017.rtf

IRT.0001.0002.0836 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 7th October 2016.rtf

IRT.0001.0002.0842 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 8th October 2016.rtf

IRT.0001.0002.0848 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 9th December 2017.rtf

IRT.0001.0002.0855 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 9th June 2017.rtf

IRT.0001.0002.0862 Care Evaluation - Care Outcomes _ Changes Shirley Fowler 13th August 2017.rtf

IRT.0001.0002.0954 Care Evaluation Shirley Fowler 13th August 2017.rtf

IRT.0001.0002.1245 Care Plan Shirley Fowler

IRT.0001.0002.1714 Daily Record_ Daily Repositioning Shirley Fowler 1 January 2018 to 1 January 2019

IRT.0001.0002.1886 Daily Record_ Food _ Fluid Intake Shirley Fowler 1 January 2017 to 1st January 2018.pdf

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

118

Exhibit Document

Exhibit

Number Number

IRT.0001.0002.1923 Daily Record_ Food _ Fluid Intake Shirley Fowler 1st January 2018 to 1st January 2019

IRT.0001.0002.1962 Daily Record_ Food _ Fluid Intake Shirley Fowler 1st July 2016 o 1st January 2017.pdf

IRT.0001.0002.2034 Daily Record_ Pain Shirley Fowler 1st January 2017 to 1st January 2018.pdf

IRT.0001.0002.2042 Daily Record_ Pain Shirley Fowler 1st January 2018 to 1st January 2019.pdf

IRT.0001.0002.2051 Daily Record_ Pain Shirley Fowler 1st July 2016 to 1st January 2017.pdf

IRT.0001.0002.2080 Dietary Details Shirley Fowler 12th April 2017.rtf

IRT.0001.0002.2083 Dietary Details Shirley Fowler 12th November 2016.rtf

IRT.0001.0002.2085 Dietary Details Shirley Fowler 16th January 2018.rtf

IRT.0001.0002.2088 Dietary Details Shirley Fowler 17th January 2018.rtf

IRT.0001.0002.2091 Dietary Details Shirley Fowler 17th March 2017.rtf

IRT.0001.0002.2096 Dietary Details Shirley Fowler 20th June 2017.rtf

IRT.0001.0002.2102 Dietary Details Shirley Fowler 21st November 2016.rtf

IRT.0001.0002.2107 Dietary Details Shirley Fowler 24th October 2017.rtf

IRT.0001.0002.2113 Dietary Details Shirley Fowler 29th October 2016.rtf

IRT.0001.0002.2117 Dietary Details Shirley Fowler 31st May 2017 2.rtf

IRT.0001.0002.2123 Dietary Details Shirley Fowler 3rd August 2018.rtf

IRT.0001.0002.2129 Dietary Details Shirley Fowler 5th June 2017 2.rtf

IRT.0001.0002.2135 Dietary Details Shirley Fowler 7th September 2017.rtf

IRT.0001.0002.2142 Falls and Other Risks _ Safety Assessment Shirley Fowler 11th October 2016.rtf

IRT.0001.0002.2146 Falls and Other Risks _ Safety Assessment Shirley Fowler 14th July 2016.rtf

IRT.0001.0002.2150 Falls and Other Risks _ Safety Assessment Shirley Fowler 15th October 2016 2.rtf

IRT.0001.0002.2154 Falls and Other Risks _ Safety Assessment Shirley Fowler 15th September 2016.rtf

IRT.0001.0002.2166 Falls and Other Risks _ Safety Assessment Shirley Fowler 19th August 2016.rtf

IRT.0001.0002.2093 Dietary Details Shirley Fowler 1st June 2017.rtf

IRT.0001.0002.2099 Dietary Details Shirley Fowler 20th November 2017.rtf

IRT.0001.0002.2104 Dietary Details Shirley Fowler 23rd October 2017.rtf

IRT.0001.0002.2110 Dietary Details Shirley Fowler 29th June 2017.rtf

IRT.0001.0002.2115 Dietary Details Shirley Fowler 2nd july 2016.rtf

IRT.0001.0002.2120 Dietary Details Shirley Fowler 31st May 2017.rtf

IRT.0001.0002.2126 Dietary Details Shirley Fowler 4th December 2017.rtf

IRT.0001.0002.2132 Dietary Details Shirley Fowler 5th June 2017.rtf

IRT.0001.0002.2138 Falls and Other Risks _ Safety Assessment Shirley Fowler 11th October 2016 2.rtf

Appendix 4 Exhibits

119

Exhibit Document

Exhibit

Number Number

IRT.0001.0002.2178 Falls and Other Risks _ Safety Assessment Shirley Fowler 29th October 2016 2.rtf

IRT.0001.0002.2182 Falls and Other Risks _ Safety Assessment Shirley Fowler 2nd July 2016.rtf

IRT.0001.0002.2190 Falls and Other Risks _ Safety Assessment Shirley Fowler 5th October 2016.rtf

IRT.0001.0002.2194 Falls and Other Risks _ Safety Assessment Shirley Fowler 6th February 2018.rtf

IRT.0001.0002.2198 Functional Assessment Shirley Fowler

IRT.0001.0002.2202 Functional Assessment Shirley Fowler 13th March 2017.rtf

IRT.0001.0002.2209 Functional Assessment Shirley Fowler 17th March 2017.rtf

IRT.0001.0002.2212 Functional Assessment Shirley Fowler 18th May 2018.rtf

IRT.0001.0002.2216 Functional Assessment Shirley Fowler 24th October 2016.rtf

IRT.0001.0002.2219 Functional Assessment Shirley Fowler 25th October 2016.rtf

IRT.0001.0002.2222 Functional Assessment Shirley Fowler 29th October 2016.rtf

IRT.0001.0002.2226 Functional Assessment Shirley Fowler 2nd April 2018.rtf

IRT.0001.0002.2230 Functional Assessment Shirley Fowler 2nd July 2016.rtf

IRT.0001.0002.2234 Functional Assessment Shirley Fowler 30th November 2016.rtf

IRT.0001.0002.2237 Functional Assessment Shirley Fowler 3rd August 2018.rtf

IRT.0001.0002.2241 Functional Assessment Shirley Fowler 3rd December 2016.rtf

IRT.0001.0002.2244 Functional Assessment Shirley Fowler 5th December 2016.rtf

IRT.0001.0002.2247 Functional Assessment Shirley Fowler 5th June 2017.rtf

IRT.0001.0002.2251 Functional Assessment Shirley Fowler 6th July 2017.rtf

IRT.0001.0002.2255 Functional Assessment Shirley Fowler 8th August 2018.rtf

IRT.0001.0002.2287 Health Management Shirley Fowler 2nd July 2016.rtf

IRT.0001.0002.2293 Health Management Shirley Fowler

IRT.0001.0002.2332 Incident Form Shirley Fowler - 1 January 2018.rtf

IRT.0001.0002.2338 Incident Form Shirley Fowler - 10 October 2016-2.rtf

IRT.0001.0002.2340 Incident Form Shirley Fowler - 10 October 2016.rtf

IRT.0001.0002.2341 Incident Form Shirley Fowler - 10 September 2018.rtf

IRT.0001.0002.2343 Incident Form Shirley Fowler - 11 July 2016.rtf

IRT.0001.0002.2346 Incident Form Shirley Fowler - 14 July 2016.rtf

IRT.0001.0002.2348 Incident Form Shirley Fowler - 15 October 2016-2.rtf

IRT.0001.0002.2351 Incident Form Shirley Fowler - 15 September 2016.rtf

IRT.0001.0002.2356 Incident Form Shirley Fowler - 17 July 2016.rtf

IRT.0001.0002.2397 Infection Record - 10 April 2018.rtf

IRT.0001.0002.2404 Infection Record - 15 September 2017.rtf

IRT.0001.0002.2405 Infection Record - 16 November 2017.rtf

IRT.0001.0002.2412 Infection Record - 25 October 2017.rtf

IRT.0001.0002.2588 Mini Nutritional Assessment (MNA) Shirley Fowler 10th August 2018.rtf

IRT.0001.0002.2591 2016 Advanced Care Directive Form.pdf

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

120

Exhibit Document

Exhibit

Number Number

IRT.0001.0002.2689 Prescription history

IRT.0001.0002.2798 2017 Clinical Paper File

IRT.0001.0002.2835 2018 New Care Evaluation

IRT.0001.0002.2847 23-24 February 2018 - Daily notes during system outage.pdf

IRT.0001.0002.2859 Nutrition Assessment Shirley Fowler 17th March 2017.rtf

IRT.0001.0002.2863 Nutrition Assessment Shirley Fowler 29th October 2016.rtf

IRT.0001.0002.2867 Nutrition Assessment Shirley Fowler 5th June 2017.rtf

IRT.0001.0002.2873 Nutrition Assessment Shirley Fowler 7th August 2018.rtf

IRT.0001.0002.2917 Pain Assessment _ Management Plan Shirley Fowler 13th December 2016.rtf

IRT.0001.0002.2926 Pain Assessment _ Management Plan Shirley Fowler 18th October 2016.rtf

IRT.0001.0002.2935 Pain Assessment _ Management Plan Shirley Fowler 28th October 2016 10.33am

IRT.0001.0002.2938 Pain Assessment _ Management Plan Shirley Fowler 28th October 2016 9.49am

IRT.0001.0002.2945 Pain Assessment _ Management Plan Shirley Fowler 29th October 2016 2.rtf

IRT.0001.0002.2960 Pain Assessment _ Management Plan Shirley Fowler 3rd December 2016.rtf

IRT.0001.0002.2995 Physical - Self Care Ability _ Preferences Shirley Fowler 29th October 2016.rtf

IRT.0001.0002.3028 Skin Assessment Shirley Fowler 14th November 2016.rtf

IRT.0001.0002.3030 Skin Assessment Shirley Fowler 16th April 2018.rtf

IRT.0001.0002.3035 Skin Assessment Shirley Fowler 17th August 2018.rtf

IRT.0001.0002.3040 Skin Assessment Shirley Fowler 18th April 2018.rtf

IRT.0001.0002.3046 Skin Assessment Shirley Fowler 20th December 2018.rtf

IRT.0001.0002.3055 Skin Assessment Shirley Fowler 21st April 2018.rtf

IRT.0001.0002.3060 Skin Assessment Shirley Fowler 27th June 2017.rtf

IRT.0001.0002.2714_E Discharge Summary Shirley Fowler 25.01.2016.pdf

IRT.0001.0002.2830 Restraint Authorisation - 3 November 2017

IRT.0001.0002.2845 2018 Resident of the Day - L Fowler

IRT.0001.0002.2856 Nutrition Assessment Shirley Fowler 14th August 2017.rtf

IRT.0001.0002.2861 Nutrition Assessment Shirley Fowler 25th April 2017.rtf

IRT.0001.0002.2865 Nutrition Assessment Shirley Fowler 2nd July 2016.rtf

IRT.0001.0002.2870 Nutrition Assessment Shirley Fowler 6th February 2018.rtf

IRT.0001.0002.2898 Oral _ Dental Assessment Shirley Fowler 2nd July 2017.rtf

IRT.0001.0002.3033 Skin Assessment Shirley Fowler 16th January 2018.rtf

IRT.0001.0002.3038 Skin Assessment Shirley Fowler 17th March 2017.rtf

IRT.0001.0002.3043 Skin Assessment Shirley Fowler 19th April 2018.rtf

IRT.0001.0002.3049 Skin Assessment Shirley Fowler 20th March 2018 2.rtf

IRT.0001.0002.3058 Skin Assessment Shirley Fowler 25th April 2017.rtf

IRT.0001.0002.3062 Skin Assessment Shirley Fowler 29th October 2016.rtf

121

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

IRT.0001.0002.3064 Skin Assessment Shirley Fowler 2nd July 2016.rtf

IRT.0001.0002.3066 Skin Assessment Shirley Fowler 3rd November 2016.rtf

IRT.0001.0002.3068 Skin Assessment Shirley Fowler 5th August 2017.rtf

IRT.0001.0002.3070 Skin Assessment Shirley Fowler 5th December 2016 11.53am

IRT.0001.0002.3072 Skin Assessment Shirley Fowler 5th December 2016 10.54am

IRT.0001.0002.3074 Skin Assessment Shirley Fowler 5th June 2017.rtf

IRT.0001.0002.3076 Skin Assessment Shirley Fowler 6th July 2017.rtf

IRT.0001.0002.3078 Skin Assessment Shirley Fowler 8th June 2018.rtf

IRT.0001.0002.3103 Allied Health Documentation Shirley Fowler 27.11.2018

IRT.0001.0002.3108 Case Management Record

IRT.0001.0002.3109 Case Management Record

IRT.0001.0002.3118 Discharge Summary Shirley Fowler 17.10.2016.pdf

IRT.0001.0002.3149 Pathology Shirley Fowler 14.11.2017.pdf

IRT.0001.0002.3158 Right Foot Swab Result Shirley Fowler 01.04.2018.pdf

IRT.0001.0002.3162 Statement of Medical DIagnosis 10.11.2016

IRT.0001.0002.3166 Wound Swab Result Shirley Fowler 08.09.2017.pdf

IRT.0001.0002.3167 Wound Swab Result Shirley Fowler 27.10.2017.pdf

IRT.0001.0002.3173 GCS- 1.7.16-1.1.19.pdf

IRT.0001.0002.3174 Urinalysis 1.7.16-1.1.19.pdf

IRT.0001.0002.3177 Weight and Vital Signs Record 1.7.16-1.1.19

IRT.0001.0002.3314 Wound chart 24.3.17.pdf

IRT.0001.0002.3320 Wound / Skin Management Plan and Evaluation 30.8.19

IRT.0001.0002.3332 Wound / Skin Management Plan and Evaluation 1.7.17.pdf

IRT.0001.0002.3336 Wound / Skin Management Plan and Evaluation 10.6.17.pdf

IRT.0001.0002.3339 Wound / Skin Management Plan and Evaluation 10.7.17.pdf

IRT.0001.0002.3344 Wound / Skin Management Plan and Evaluation 12.7.17.pdf

IRT.0001.0002.3349 Wound / Skin Management Plan and Evaluation 12.8.17.pdf

IRT.0001.0002.3356 Wound / Skin Management Plan and Evaluation 14.7.17.pdf

IRT.0001.0002.3362 Wound / Skin Management Plan and Evaluation 15.7.17.pdf

IRT.0001.0002.3368 Wound / Skin Management Plan and Evaluation 15.8.17.pdf

IRT.0001.0002.3375 Wound / Skin Management Plan and Evaluation 16.7.17.pdf

IRT.0001.0002.3381 Wound / Skin Management Plan and Evaluation 17.7.17.pdf

IRT.0001.0002.3387 Wound / Skin Management Plan and Evaluation 17.8.17.pdf

IRT.0001.0002.3394 Wound / Skin Management Plan and Evaluation 18.7.17.pdf

IRT.0001.0002.3400 Wound / Skin Management Plan and Evaluation 19.8.17.pdf

IRT.0001.0002.3410 Wound / Skin Management Plan and Evaluation 20.7.17.pdf

IRT.0001.0002.3416 Wound / Skin Management Plan and Evaluation 20.8.17

IRT.0001.0002.3423 Wound / Skin Management Plan and Evaluation 21.7.17.pdf

IRT.0001.0002.3429 Wound / Skin Management Plan and Evaluation 22.7.17.pdf

IRT.0001.0002.3435 Wound / Skin Management Plan and Evaluation 23.8.17.pdf

IRT.0001.0002.3443 Wound / Skin Management Plan and Evaluation 26.8.17.pdf

122

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document Number Number

IRT.0001.0002.3452

Exhibit

Wound / Skin Management Plan and Evaluation 27.7.17.pdf

IRT.0001.0002.3459 Wound / Skin Management Plan and Evaluation 27.8.17.pdf

IRT.0001.0002.3468 Wound / Skin Management Plan and Evaluation 28.8.17.pdf

IRT.0001.0002.3477 Wound / Skin Management Plan and Evaluation 29.8.17.pdf

IRT.0001.0002.3489 Wound / Skin Management Plan and Evaluation 3.7.17

IRT.0001.0002.3493 Wound / Skin Management Plan and Evaluation 30.8.17.pdf

IRT.0001.0002.3502 Wound / Skin Management Plan and Evaluation 31.7.17.pdf

IRT.0001.0002.3509 Wound / Skin Management Plan and Evaluation 4.7.17

IRT.0001.0002.3513 Wound / Skin Management Plan and Evaluation 4.8.17.pdf

IRT.0001.0002.3520 Wound / Skin Management Plan and Evaluation 6.7.17.pdf

IRT.0001.0002.3527 Wound / Skin Management Plan and Evaluation 7.7.17.pdf

IRT.0001.0002.3531 Wound / Skin Management Plan and Evaluation 7.8.17

IRT.0001.0002.3538 Wound / Skin Management Plan and Evaluation 8.8.17.pdf

IRT.0001.0002.3545 Wound / Skin Management Plan and Evaluation 9.8.17.pdf

IRT.0001.0002.3552 Wound / Skin Management Plan and Evaluation 1.10.17.pdf

IRT.0001.0002.3563 Wound / Skin Management Plan and Evaluation 1.11.17.pdf

IRT.0001.0002.3575 Wound / Skin Management Plan and Evaluation 10.10.17.pdf

IRT.0001.0002.3585 Wound / Skin Management Plan and Evaluation 11.10.17.pdf

IRT.0001.0002.3595 Wound / Skin Management Plan and Evaluation 12.10.17.pdf

IRT.0001.0002.3605 Wound / Skin Management Plan and Evaluation 13.10.17.pdf

IRT.0001.0002.3615 Wound / Skin Management Plan and Evaluation 14.10.17.pdf

IRT.0001.0002.3625 Wound / Skin Management Plan and Evaluation 16.10.17.pdf

IRT.0001.0002.3635 Wound / Skin Management Plan and Evaluation 17.10.17.pdf

IRT.0001.0002.3645 Wound / Skin Management Plan and Evaluation 18.10.17.pdf

IRT.0001.0002.3655 Wound / Skin Management Plan and Evaluation 19.10.17.pdf

IRT.0001.0002.3668 Wound / Skin Management Plan and Evaluation 2.10.17.pdf

IRT.0001.0002.3679 Wound / Skin Management Plan and Evaluation 20.10.17.pdf

IRT.0001.0002.3689 Wound / Skin Management Plan and Evaluation 21.10.17.pdf

IRT.0001.0002.3699 Wound / Skin Management Plan and Evaluation 22.10.17.pdf

IRT.0001.0002.3709 Wound / Skin Management Plan and Evaluation 27.9.17.pdf

IRT.0001.0002.3719 Wound / Skin Management Plan and Evaluation 28.9.17.pdf

IRT.0001.0002.3730 Wound / Skin Management Plan and Evaluation 3.10.17.pdf

IRT.0001.0002.3741 Wound / Skin Management Plan and Evaluation 30.9.17.pdf

IRT.0001.0002.3752 Wound / Skin Management Plan and Evaluation 4.10.17.pdf

IRT.0001.0002.3763 Wound / Skin Management Plan and Evaluation 5.10.17.pdf

IRT.0001.0002.3774 Wound / Skin Management Plan and Evaluation 6.10.17.pdf

IRT.0001.0002.3785 Wound / Skin Management Plan and Evaluation 7.10.17.pdf

IRT.0001.0002.3796 Wound / Skin Management Plan and Evaluation 8.10.17.pdf

IRT.0001.0002.3807 Wound / Skin Management Plan and Evaluation 9.10.17.pdf

IRT.0001.0002.3817 Wound / Skin Management Plan and Evaluation 1.12.17.pdf

IRT.0001.0002.3836 Wound / Skin Management Plan and Evaluation 1.9.17.pdf

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

123

IRT.0001.0002.3845 Wound / Skin Management Plan and Evaluation 10.12.17.pdf

IRT.0001.0002.3858 Wound / Skin Management Plan and Evaluation 10.9.17.pdf

IRT.0001.0002.3867 Wound / Skin Management Plan and Evaluation 11.11.17.pdf

IRT.0001.0002.3879 Wound / Skin Management Plan and Evaluation 11.12.17.pdf

IRT.0001.0002.3895 Wound / Skin Management Plan and Evaluation 12.12.17.pdf

IRT.0001.0002.3911 Wound / Skin Management Plan and Evaluation 12.9.17.pdf

IRT.0001.0002.3920 Wound / Skin Management Plan and Evaluation 13.11.17.pdf

IRT.0001.0002.3932 Wound / Skin Management Plan and Evaluation 13.12.17.pdf

IRT.0001.0002.3948 Wound / Skin Management Plan and Evaluation 13.9.17.pdf

IRT.0001.0002.3958 Wound / Skin Management Plan and Evaluation 14.11.17.pdf

IRT.0001.0002.3970 Wound / Skin Management Plan and Evaluation 14.12.17.pdf

IRT.0001.0002.3986 Wound / Skin Management Plan and Evaluation 14.9.17.pdf

IRT.0001.0002.3996 Wound / Skin Management Plan and Evaluation 15.11.17.pdf

IRT.0001.0002.4017 Wound / Skin Management Plan and Evaluation 15.9.17.pdf

IRT.0001.0002.4027 Wound / Skin Management Plan and Evaluation 16.12.17.pdf

IRT.0001.0002.4043 Wound / Skin Management Plan and Evaluation 16.9.17.pdf

IRT.0001.0002.4054 Wound / Skin Management Plan and Evaluation 17.11.17.pdf

IRT.0001.0002.4066 Wound / Skin Management Plan and Evaluation 17.12.17.pdf

IRT.0001.0002.4082 Wound / Skin Management Plan and Evaluation 17.9.17.pdf

IRT.0001.0002.4099 Wound / Skin Management Plan and Evaluation 18.9.17.pdf

IRT.0001.0002.4110 Wound / Skin Management Plan and Evaluation 19.11.17.pdf

IRT.0001.0002.4122 Wound / Skin Management Plan and Evaluation 19.12.17.pdf

IRT.0001.0002.4144 Wound / Skin Management Plan and Evaluation 19.9.17.pdf

IRT.0001.0002.4158 Wound / Skin Management Plan and Evaluation 2 12.7.17

IRT.0001.0002.4163 Wound / Skin Management Plan and Evaluation 2 20.7.17

IRT.0001.0002.4169 Wound / Skin Management Plan and Evaluation 2 21.7.17

IRT.0001.0002.4175 Wound / Skin Management Plan and Evaluation 2 27.7.17

IRT.0001.0002.4182 Wound / Skin Management Plan and Evaluation 2 27.8.17

IRT.0001.0002.4191 Wound / Skin Management Plan and Evaluation 2 29.8.17

IRT.0001.0002.4211 Wound / Skin Management Plan and Evaluation 2 23.10.17

IRT.0001.0002.4234 Wound / Skin Management Plan and Evaluation 2 9.9.17

IRT.0001.0002.4243 Wound / Skin Management Plan and Evaluation 2.12.17.pdf

IRT.0001.0002.4263 Wound / Skin Management Plan and Evaluation 20.9.17.pdf

IRT.0001.0002.4274 Wound / Skin Management Plan and Evaluation 21.12.17.pdf

IRT.0001.0002.4294 Wound / Skin Management Plan and Evaluation 21.9.17.pdf

IRT.0001.0002.4304 Wound / Skin Management Plan and Evaluation 22.11.17.pdf

IRT.0001.0002.4325 Wound / Skin Management Plan and Evaluation 22.9.17.pdf

IRT.0001.0002.4335 Wound / Skin Management Plan and Evaluation 23.10.17.pdf

IRT.0001.0002.4345 Wound / Skin Management Plan and Evaluation 23.12.17.pdf

IRT.0001.0002.4368 Wound / Skin Management Plan and Evaluation 23.9.17.pdf

IRT.0001.0002.4378 Wound / Skin Management Plan and Evaluation 24.11.17.pdf

124

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document Number Number

Exhibit

IRT.0001.0002.4390 Wound / Skin Management Plan and Evaluation 24.12.17.pdf

IRT.0001.0002.4407 Wound / Skin Management Plan and Evaluation 24.9.17.pdf

IRT.0001.0002.4417 Wound / Skin Management Plan and Evaluation 2410.17.pdf

IRT.0001.0002.4428 Wound / Skin Management Plan and Evaluation 25.10.17.pdf

IRT.0001.0002.4439 Wound / Skin Management Plan and Evaluation 25.11.17.pdf

IRT.0001.0002.4452 Wound / Skin Management Plan and Evaluation 25.12.17.pdf

IRT.0001.0002.4472 Wound / Skin Management Plan and Evaluation 25.9.17.pdf

IRT.0001.0002.4482 Wound / Skin Management Plan and Evaluation 26.10.17.pdf

IRT.0001.0002.4500 Wound / Skin Management Plan and Evaluation 26.9.17.pdf

IRT.0001.0002.4510 Wound / Skin Management Plan and Evaluation 27.10.17.pdf

IRT.0001.0002.4522 Wound / Skin Management Plan and Evaluation 27.11.17.pdf

IRT.0001.0002.4535 Wound / Skin Management Plan and Evaluation 27.12.17.pdf

IRT.0001.0002.4558 Wound / Skin Management Plan and Evaluation 28.10.17.pdf

IRT.0001.0002.4570 Wound / Skin Management Plan and Evaluation 28.11.17.pdf

IRT.0001.0002.4583 Wound / Skin Management Plan and Evaluation 28.12.17.pdf

IRT.0001.0002.4597 Wound / Skin Management Plan and Evaluation 29.10.17.pdf

IRT.0001.0002.4608 Wound / Skin Management Plan and Evaluation 29.11.17.pdf

IRT.0001.0002.4621 Wound / Skin Management Plan and Evaluation 29.12.17.pdf

IRT.0001.0002.4641 Wound / Skin Management Plan and Evaluation 3 12.10.17

IRT.0001.0002.4658 Wound / Skin Management Plan and Evaluation 3.11.17.pdf

IRT.0001.0002.4670 Wound / Skin Management Plan and Evaluation 3.12.17.pdf

IRT.0001.0002.4683 Wound / Skin Management Plan and Evaluation 3.9.17.pdf

IRT.0001.0002.4698 Wound / Skin Management Plan and Evaluation 31.12.17.pdf

IRT.0001.0002.4712 Wound / Skin Management Plan and Evaluation 31.8.19

IRT.0001.0002.4724 Wound / Skin Management Plan and Evaluation 4.12.17.pdf

IRT.0001.0002.4737 Wound / Skin Management Plan and Evaluation 4.9.17.pdf

IRT.0001.0002.4746 Wound / Skin Management Plan and Evaluation 5.11.17.pdf

IRT.0001.0002.4758 Wound / Skin Management Plan and Evaluation 5.12.17.pdf

IRT.0001.0002.4774 Wound / Skin Management Plan and Evaluation 5.9.17.pdf

IRT.0001.0002.4783 Wound / Skin Management Plan and Evaluation 6.12.17.pdf

IRT.0001.0002.4796 Wound / Skin Management Plan and Evaluation 7.12.17.pdf

IRT.0001.0002.4812 Wound / Skin Management Plan and Evaluation 7.9.17.pdf

IRT.0001.0002.4821 Wound / Skin Management Plan and Evaluation 8.11.17.pdf

IRT.0001.0002.4833 Wound / Skin Management Plan and Evaluation 8.12.17.pdf

IRT.0001.0002.4849 Wound / Skin Management Plan and Evaluation 8.9.17.pdf

IRT.0001.0002.4858 Wound / Skin Management Plan and Evaluation 9.11.17.pdf

IRT.0001.0002.4870 Wound / Skin Management Plan and Evaluation 9.12.17.pdf

IRT.0001.0002.4886 Wound / Skin Management Plan and Evaluation 9.9.17.pdf

IRT.0001.0002.4895 Wound / Skin Management Plan and Evaluation 10.10.17

IRT.0001.0002.4908 Wound / Skin Management Plan and Evaluation 19.8.17

IRT.0001.0002.4915 Wound / Skin Management Plan and Evaluation 26.8.17

125

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

IRT.0001.0002.4924 Wound / Skin Management Plan and Evaluation 7.7.17

IRT.0001.0002.4928 Wound / Skin Management Plan and Evaluation 9.8.17

IRT.0001.0002.4935 Wound / Skin Management Plan and Evaluation 12.10.17

IRT.0001.0002.4945 Wound / Skin Management Plan and Evaluation 12.12.17

IRT.0001.0002.4958 Wound / Skin Management Plan and Evaluation 14.10.17

IRT.0001.0002.4968 Wound / Skin Management Plan and Evaluation 22.10.17

IRT.0001.0002.4978 Wound / Skin Management Plan and Evaluation 22.11.17

IRT.0001.0002.5000 Wound / Skin Management Plan and Evaluation 24.9.17

IRT.0001.0002.5010 Wound / Skin Management Plan and Evaluation 26.9.17

IRT.0001.0002.5020 Wound / Skin Management Plan and Evaluation 27.9.17

IRT.0001.0002.5031 Wound / Skin Management Plan and Evaluation 28.11.17

IRT.0001.0002.5044 Wound / Skin Management Plan and Evaluation 28.9.17

IRT.0001.0002.5055 Wound / Skin Management Plan and Evaluation 30.9.17

IRT.0001.0002.5066 Wound / Skin Management Plan and Evaluation 4.12.17

IRT.0001.0002.5079 Wound / Skin Management Plan and Evaluation 5.12.17

IRT.0001.0002.5092 Wound / Skin Management Plan and Evaluation 8.10.17

IRT.0001.0002.5103 Wound / Skin Management Plan and Evaluation 1.11.17

IRT.0001.0002.5115 Wound / Skin Management Plan and Evaluation 1.12.17

IRT.0001.0002.5128 Wound / Skin Management Plan and Evaluation 12.9.17

IRT.0001.0002.5137 Wound / Skin Management Plan and Evaluation 14.9.17

IRT.0001.0002.5147 Wound / Skin Management Plan and Evaluation 15.11.17

IRT.0001.0002.5159 Wound / Skin Management Plan and Evaluation 15.9.17

IRT.0001.0002.5170 Wound / Skin Management Plan and Evaluation 16.9.17

IRT.0001.0002.5192 Wound / Skin Management Plan and Evaluation 24.10.17

IRT.0001.0002.5203 Wound / Skin Management Plan and Evaluation 24.11.17

IRT.0001.0002.5215 Wound / Skin Management Plan and Evaluation 27.11.17

IRT.0001.0002.5228 Wound / Skin Management Plan and Evaluation 27.12.17

IRT.0001.0002.5241 Wound / Skin Management Plan and Evaluation 28.10.17

IRT.0001.0002.5253 Wound / Skin Management Plan and Evaluation 29.10.17

IRT.0001.0002.5264 Wound / Skin Management Plan and Evaluation 4.10.17

IRT.0001.0002.5275 Wound / Skin Management Plan and Evaluation 7.9.17

IRT.0001.0002.5284 Wound / Skin Management Plan and Evaluation 8.11.17

IRT.0001.0002.5296 Wound / Skin Management Plan and Evaluation 8.9.17

IRT.0001.0002.5305 Wound / Skin Management Plan and Evaluation 9.9.17

IRT.0001.0002.5314 Wound / Skin Management Plan and Evaluation 14.10.17

IRT.0001.0002.5324 Wound / Skin Management Plan and Evaluation 24.10.17

IRT.0001.0002.5335 Wound / Skin Management Plan and Evaluation 26.9.17

IRT.0001.0002.5345 Wound / Skin Management Plan and Evaluation 27.9.17

IRT.0001.0002.5356 Wound / Skin Management Plan and Evaluation 30.9.17

IRT.0001.0002.5367 Wound / Skin Management Plan and Evaluation 8.10.17

IRT.0001.0002.5377 Wound / Skin Management Plan and Evaluation 10.9.17

126

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document Number Number

Exhibit

IRT.0001.0002.5386 Wound / Skin Management Plan and Evaluation3 11.9.17.pdf

IRT.0001.0002.5395 Wound / Skin Management Plan and Evaluation 20.9.17

IRT.0001.0002.5406 Wound / Skin Management Plan and Evaluation 22.11.17

IRT.0001.0002.5418 Wound / Skin Management Plan and Evaluation 22.9.17

IRT.0001.0002.5428 Wound / Skin Management Plan and Evaluation 28.10.17

IRT.0001.0002.5439 Wound / Skin Management Plan and Evaluation 29.10.17

IRT.0001.0002.5450 Wound / Skin Management Plan and Evaluation 8.9.17

IRT.0001.0002.5459 Wound / Skin Management Plan and Evaluation 12.10.17

IRT.0001.0002.5469 Wound / Skin Management Plan and Evaluation 26.9.17

IRT.0001.0002.5482 Wound / Skin Management Plan and Evaluation 10.9.17

IRT.0001.0002.5512 Wound / Skin Management Plan and Evaluation 10.1.18.pdf

IRT.0001.0002.5531 Wound / Skin Management Plan and Evaluation 11.1.18

IRT.0001.0002.5544 Wound / Skin Management Plan and Evaluation 11.9.18.pdf

IRT.0001.0002.5547 Wound / Skin Management Plan and Evaluation 12.1.18.pdf

IRT.0001.0002.5561 Wound / Skin Management Plan and Evaluation 12.9.18.pdf

IRT.0001.0002.5564 Wound / Skin Management Plan and Evaluation 13.1.18.pdf

IRT.0001.0002.5580 Wound / Skin Management Plan and Evaluation 13.9.18.pdf

IRT.0001.0002.5583 Wound / Skin Management Plan and Evaluation 14.1.18.pdf

IRT.0001.0002.5597 Wound / Skin Management Plan and Evaluation 14.9.18.pdf

IRT.0001.0002.5601 Wound / Skin Management Plan and Evaluation 15.9.18.pdf

IRT.0001.0002.5604 Wound / Skin Management Plan and Evaluation 16.1.18.pdf

IRT.0001.0002.5617 Wound / Skin Management Plan and Evaluation 17.1.18.pdf

IRT.0001.0002.5632 Wound / Skin Management Plan and Evaluation 17.9.18.pdf

IRT.0001.0002.5635 Wound / Skin Management Plan and Evaluation 18.11.18.pdf

IRT.0001.0002.5639 Wound / Skin Management Plan and Evaluation 2.2.18.pdf

IRT.0001.0002.5652 Wound / Skin Management Plan and Evaluation 20.9.18.pdf

IRT.0001.0002.5655 Wound / Skin Management Plan and Evaluation 21.1.18.pdf

IRT.0001.0002.5668 Wound / Skin Management Plan and Evaluation 21.9.18.pdf

IRT.0001.0002.5673 Wound / Skin Management Plan and Evaluation 22.9.18.pdf

IRT.0001.0002.5676 Wound / Skin Management Plan and Evaluation 23.1.18.pdf

IRT.0001.0002.5689 Wound / Skin Management Plan and Evaluation 24.1.18.pdf

IRT.0001.0002.5702 Wound / Skin Management Plan and Evaluation 24.9.18.pdf

IRT.0001.0002.5705 Wound / Skin Management Plan and Evaluation 25.1.18.pdf

IRT.0001.0002.5718 Wound / Skin Management Plan and Evaluation 26.1.18.pdf

IRT.0001.0002.5731 Wound / Skin Management Plan and Evaluation 26.9.18.pdf

IRT.0001.0002.5734 Wound / Skin Management Plan and Evaluation 27.1.18.pdf

IRT.0001.0002.5747 Wound / Skin Management Plan and Evaluation 27.9.18.pdf

IRT.0001.0002.5750 Wound / Skin Management Plan and Evaluation 28.1.18.pdf

IRT.0001.0002.5763 Wound / Skin Management Plan and Evaluation 29.1.18.pdf

IRT.0001.0002.5776 Wound / Skin Management Plan and Evaluation 3.7.18

IRT.0001.0002.5780 Wound / Skin Management Plan and Evaluation 30.1.18.pdf

127

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

IRT.0001.0002.5793 Wound / Skin Management Plan and Evaluation 31.1.18.pdf

IRT.0001.0002.5810 Wound / Skin Management Plan and Evaluation 1.1.18.pdf

IRT.0001.0002.5824 Wound / Skin Management Plan and Evaluation 1.3.18.pdf

IRT.0001.0002.5839 Wound / Skin Management Plan and Evaluation 1.5.18

IRT.0001.0002.5857 Wound / Skin Management Plan and Evaluation 1.6.18

IRT.0001.0002.5871 Wound / Skin Management Plan and Evaluation 1.7.18

IRT.0001.0002.5875 Wound / Skin Management Plan and Evaluation 10.2.18.pdf

IRT.0001.0002.5889 Wound / Skin Management Plan and Evaluation 13.2.18

IRT.0001.0002.5903 Wound / Skin Management Plan and Evaluation 10.4.18

IRT.0001.0002.5920 Wound / Skin Management Plan and Evaluation 10.5.18

IRT.0001.0002.5938 Wound / Skin Management Plan and Evaluation 10.6.18

IRT.0001.0002.5942 Wound / Skin Management Plan and Evaluation 10.7.18

IRT.0001.0002.5947 Wound / Skin Management Plan and Evaluation 10.8.18.pdf

IRT.0001.0002.5951 Wound / Skin Management Plan and Evaluation 11.2.18.pdf

IRT.0001.0002.5965 Wound / Skin Management Plan and Evaluation 11.3.18.pdf

IRT.0001.0002.5980 Wound / Skin Management Plan and Evaluation 11.5.18

IRT.0001.0002.5998 Wound / Skin Management Plan and Evaluation 11.6.18

IRT.0001.0002.6002 Wound / Skin Management Plan and Evaluation 11.7.18

IRT.0001.0002.6007 Wound / Skin Management Plan and Evaluation 11.8.18

IRT.0001.0002.6010 Wound / Skin Management Plan and Evaluation 12.4.18

IRT.0001.0002.6027 Wound / Skin Management Plan and Evaluation 12.5.18

IRT.0001.0002.6045 Wound / Skin Management Plan and Evaluation 12.6.18

IRT.0001.0002.6049 Wound / Skin Management Plan and Evaluation 12.7.18

IRT.0001.0002.6054 Wound / Skin Management Plan and Evaluation 13.2.18

IRT.0001.0002.6068 Wound / Skin Management Plan and Evaluation 13.3.18.pdf

IRT.0001.0002.6083 Wound / Skin Management Plan and Evaluation 13.5.18

IRT.0001.0002.6101 Wound / Skin Management Plan and Evaluation 13.6.18

IRT.0001.0002.6105 Wound / Skin Management Plan and Evaluation 13.7.18

IRT.0001.0002.6110 Wound / Skin Management Plan and Evaluation 14.4.18

IRT.0001.0002.6127 Wound / Skin Management Plan and Evaluation 14.5.18

IRT.0001.0002.6141 Wound / Skin Management Plan and Evaluation 14.7.18

IRT.0001.0002.6147 Wound / Skin Management Plan and Evaluation 14.8.18.pdf

IRT.0001.0002.6150 Wound / Skin Management Plan and Evaluation 15.2.18.pdf

IRT.0001.0002.6164 Wound / Skin Management Plan and Evaluation 15.3.18.pdf

IRT.0001.0002.6179 Wound / Skin Management Plan and Evaluation 15.4.18.pdf

IRT.0001.0002.6196 Wound / Skin Management Plan and Evaluation 15.5.18.pdf

IRT.0001.0002.6210 Wound / Skin Management Plan and Evaluation 15.6.18.pdf

IRT.0001.0002.6214 Wound / Skin Management Plan and Evaluation 15.7.18.pdf

IRT.0001.0002.6220 Wound / Skin Management Plan and Evaluation 16.2.18.pdf

IRT.0001.0002.6234 Wound / Skin Management Plan and Evaluation 16.4.18

IRT.0001.0002.6251 Wound / Skin Management Plan and Evaluation 16.5.18.pdf

128

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document Number Number

IRT.0001.0002.6265

Exhibit

Wound / Skin Management Plan and Evaluation 16.6.18.pdf

IRT.0001.0002.6269 Wound / Skin Management Plan and Evaluation 16.7.18.pdf

IRT.0001.0002.6274 Wound / Skin Management Plan and Evaluation 17.2.18.pdf

IRT.0001.0002.6288 Wound / Skin Management Plan and Evaluation 17.3.18.pdf

IRT.0001.0002.6303 Wound / Skin Management Plan and Evaluation 17.4.18.pdf

IRT.0001.0002.6320 Wound / Skin Management Plan and Evaluation 17.5.18.pdf

IRT.0001.0002.6334 Wound / Skin Management Plan and Evaluation 17.6.18.pdf

IRT.0001.0002.6338 Wound / Skin Management Plan and Evaluation 17.7.18.pdf

IRT.0001.0002.6343 Wound / Skin Management Plan and Evaluation 18.3.18.pdf

IRT.0001.0002.6359 Wound / Skin Management Plan and Evaluation 18.4.18.pdf

IRT.0001.0002.6376 Wound / Skin Management Plan and Evaluation 18.5.18.pdf

IRT.0001.0002.6390 Wound / Skin Management Plan and Evaluation 19.2.18.pdf

IRT.0001.0002.6404 Wound / Skin Management Plan and Evaluation 19.3.18.pdf

IRT.0001.0002.6421 Wound / Skin Management Plan and Evaluation 19.4.18.pdf

IRT.0001.0002.6438 Wound / Skin Management Plan and Evaluation 19.5.18.pdf

IRT.0001.0002.6452 Wound / Skin Management Plan and Evaluation 19.6.18.pdf

IRT.0001.0002.6456 Wound / Skin Management Plan and Evaluation 19.7.18.pdf

IRT.0001.0002.6461 Wound / Skin Management Plan and Evaluation 19.8.18.pdf

IRT.0001.0002.6465 Wound / Skin Management Plan and Evaluation 2 11.6.18.pdf

IRT.0001.0002.6469 Wound / Skin Management Plan and Evaluation 2 22.6.18.pdf

IRT.0001.0002.6473 Wound / Skin Management Plan and Evaluation 2 8.7.18.pdf

IRT.0001.0002.6478 Wound / Skin Management Plan and Evaluation 2.1.18.pdf

IRT.0001.0002.6493 Wound / Skin Management Plan and Evaluation 2.4.18.pdf

IRT.0001.0002.6509 Wound / Skin Management Plan and Evaluation 2.5.18.pdf

IRT.0001.0002.6527 Wound / Skin Management Plan and Evaluation 2.6.18.pdf

IRT.0001.0002.6541 Wound / Skin Management Plan and Evaluation 2.8.18.pdf

IRT.0001.0002.6546 Wound / Skin Management Plan and Evaluation 20.1.18.pdf

IRT.0001.0002.6560 Wound / Skin Management Plan and Evaluation 20.2.18.pdf

IRT.0001.0002.6574 Wound / Skin Management Plan and Evaluation 20.3.18.pdf

IRT.0001.0002.6591 Wound / Skin Management Plan and Evaluation 20.4.18.pdf

IRT.0001.0002.6608 Wound / Skin Management Plan and Evaluation 20.5.18.pdf

IRT.0001.0002.6623 Wound / Skin Management Plan and Evaluation 20.6.18.pdf

IRT.0001.0002.6627 Wound / Skin Management Plan and Evaluation 20.7.18.pdf

IRT.0001.0002.6632 Wound / Skin Management Plan and Evaluation 21.2.18.pdf

IRT.0001.0002.6646 Wound / Skin Management Plan and Evaluation 21.3.18.pdf

IRT.0001.0002.6663 Wound / Skin Management Plan and Evaluation 21.5.18.pdf

IRT.0001.0002.6678 Wound / Skin Management Plan and Evaluation 21.6.18.pdf

IRT.0001.0002.6682 Wound / Skin Management Plan and Evaluation 21.7.18.pdf

IRT.0001.0002.6687 Wound / Skin Management Plan and Evaluation 22.4.18.pdf

IRT.0001.0002.6704 Wound / Skin Management Plan and Evaluation 22.5.18.pdf

IRT.0001.0002.6719 Wound / Skin Management Plan and Evaluation 22.6.18.pdf

129

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

IRT.0001.0002.6723 Wound / Skin Management Plan and Evaluation 22.7.18.pdf

IRT.0001.0002.6728 Wound / Skin Management Plan and Evaluation 23.2.18.pdf

IRT.0001.0002.6742 Wound / Skin Management Plan and Evaluation 23.3.18.pdf

IRT.0001.0002.6758 Wound / Skin Management Plan and Evaluation 23.4.18.pdf

IRT.0001.0002.6775 Wound / Skin Management Plan and Evaluation 23.5.18.pdf

IRT.0001.0002.6791 Wound / Skin Management Plan and Evaluation 23.6.18.pdf

IRT.0001.0002.6795 Wound / Skin Management Plan and Evaluation 23.7.18.pdf

IRT.0001.0002.6800 Wound / Skin Management Plan and Evaluation 24.4.18.pdf

IRT.0001.0002.6817 Wound / Skin Management Plan and Evaluation 24.5.18.pdf

IRT.0001.0002.6833 Wound / Skin Management Plan and Evaluation 24.6.18.pdf

IRT.0001.0002.6837 Wound / Skin Management Plan and Evaluation 24.7.18.pdf

IRT.0001.0002.6842 Wound / Skin Management Plan and Evaluation 25.2.18.pdf

IRT.0001.0002.6856 Wound / Skin Management Plan and Evaluation 25.3.18.pdf

IRT.0001.0002.6872 Wound / Skin Management Plan and Evaluation 25.4.18.pdf

IRT.0001.0002.6889 Wound / Skin Management Plan and Evaluation 25.5.18.pdf

IRT.0001.0002.6905 Wound / Skin Management Plan and Evaluation 25.6.18.pdf

IRT.0001.0002.6909 Wound / Skin Management Plan and Evaluation 25.7.18.pdf

IRT.0001.0002.6914 Wound / Skin Management Plan and Evaluation 26.2.18.pdf

IRT.0001.0002.6928 Wound / Skin Management Plan and Evaluation 26.5.18.pdf

IRT.0001.0002.6944 Wound / Skin Management Plan and Evaluation 26.6.18.pdf

IRT.0001.0002.6948 Wound / Skin Management Plan and Evaluation 27.2.18.pdf

IRT.0001.0002.6963 Wound / Skin Management Plan and Evaluation 27.3.18.pdf

IRT.0001.0002.6979 Wound / Skin Management Plan and Evaluation 27.4.18.pdf

IRT.0001.0002.6996 Wound / Skin Management Plan and Evaluation 27.5.18.pdf

IRT.0001.0002.7012 Wound / Skin Management Plan and Evaluation 27.6.18.pdf

IRT.0001.0002.7016 Wound / Skin Management Plan and Evaluation 27.7.18.pdf

IRT.0001.0002.7021 Wound / Skin Management Plan and Evaluation 28.3.18.pdf

IRT.0001.0002.7037 Wound / Skin Management Plan and Evaluation 28.4.18.pdf

IRT.0001.0002.7055 Wound / Skin Management Plan and Evaluation 28.5.18.pdf

IRT.0001.0002.7071 Wound / Skin Management Plan and Evaluation 28.7.18.pdf

IRT.0001.0002.7076 Wound / Skin Management Plan and Evaluation 29.3.18.pdf

IRT.0001.0002.7092 Wound / Skin Management Plan and Evaluation 29.4.18.pdf

IRT.0001.0002.7109 Wound / Skin Management Plan and Evaluation 29.5.18.pdf

IRT.0001.0002.7123 Wound / Skin Management Plan and Evaluation 29.6.18.pdf

IRT.0001.0002.7127 Wound / Skin Management Plan and Evaluation 29.7.18.pdf

IRT.0001.0002.7132 Wound / Skin Management Plan and Evaluation 3.1.18.pdf

IRT.0001.0002.7147 Wound / Skin Management Plan and Evaluation 3.2.18.pdf

IRT.0001.0002.7160 Wound / Skin Management Plan and Evaluation 3.3.18.pdf

IRT.0001.0002.7175 Wound / Skin Management Plan and Evaluation 3.6.18.pdf

IRT.0001.0002.7189 Wound / Skin Management Plan and Evaluation 3.8.18.pdf

IRT.0001.0002.7194 Wound / Skin Management Plan and Evaluation 30.4.18.pdf

130

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document Number Number

IRT.0001.0002.7211

Exhibit

Wound / Skin Management Plan and Evaluation 30.5.18.pdf

IRT.0001.0002.7225 Wound / Skin Management Plan and Evaluation 30.6.18.pdf

IRT.0001.0002.7229 Wound / Skin Management Plan and Evaluation 31.3.18.pdf

IRT.0001.0002.7246 Wound / Skin Management Plan and Evaluation 31.5.18.pdf

IRT.0001.0002.7260 Wound / Skin Management Plan and Evaluation 31.7.18.pdf

IRT.0001.0002.7265 Wound / Skin Management Plan and Evaluation 4.1.18.pdf

IRT.0001.0002.7280 Wound / Skin Management Plan and Evaluation 4.2.18.pdf

IRT.0001.0002.7293 Wound / Skin Management Plan and Evaluation 4.4.18.pdf

IRT.0001.0002.7309 Wound / Skin Management Plan and Evaluation 4.5.18.pdf

IRT.0001.0002.7327 Wound / Skin Management Plan and Evaluation 4.6.18.pdf

IRT.0001.0002.7341 Wound / Skin Management Plan and Evaluation 4.7.18.pdf

IRT.0001.0002.7345 Wound / Skin Management Plan and Evaluation 4.8.18.pdf

IRT.0001.0002.7350 Wound / Skin Management Plan and Evaluation 4.9.18.pdf

IRT.0001.0002.7354 Wound / Skin Management Plan and Evaluation 5.1.18.pdf

IRT.0001.0002.7369 Wound / Skin Management Plan and Evaluation 5.2.18.pdf

IRT.0001.0002.7382 Wound / Skin Management Plan and Evaluation 5.3.18.pdf

IRT.0001.0002.7397 Wound / Skin Management Plan and Evaluation 5.4.18.pdf

IRT.0001.0002.7413 Wound / Skin Management Plan and Evaluation 5.5.18.pdf

IRT.0001.0002.7431 Wound / Skin Management Plan and Evaluation 5.6.18.pdf

IRT.0001.0002.7445 Wound / Skin Management Plan and Evaluation 5.7.18.pdf

IRT.0001.0002.7449 Wound / Skin Management Plan and Evaluation 5.8.18.pdf

IRT.0001.0002.7458 Wound / Skin Management Plan and Evaluation 6.4.18.pdf

IRT.0001.0002.7475 Wound / Skin Management Plan and Evaluation 6.5.18.pdf

IRT.0001.0002.7493 Wound / Skin Management Plan and Evaluation 6.6.18.pdf

IRT.0001.0002.7507 Wound / Skin Management Plan and Evaluation 6.7.18.pdf

IRT.0001.0002.7511 Wound / Skin Management Plan and Evaluation 6.8.18.pdf

IRT.0001.0002.7520 Wound / Skin Management Plan and Evaluation 7.1.18.pdf

IRT.0001.0002.7537 Wound / Skin Management Plan and Evaluation 7.2.18.pdf

IRT.0001.0002.7550 Wound / Skin Management Plan and Evaluation 7.3.18.pdf

IRT.0001.0002.7565 Wound / Skin Management Plan and Evaluation 7.4.18.pdf

IRT.0001.0002.7582 Wound / Skin Management Plan and Evaluation 7.5.18.pdf

IRT.0001.0002.7600 Wound / Skin Management Plan and Evaluation 7.6.18.pdf

IRT.0001.0002.7614 Wound / Skin Management Plan and Evaluation 7.7.18.pdf

IRT.0001.0002.7621 Wound / Skin Management Plan and Evaluation 8.2.18.pdf

IRT.0001.0002.7634 Wound / Skin Management Plan and Evaluation 8.4.18.pdf

IRT.0001.0002.7651 Wound / Skin Management Plan and Evaluation 8.5.18.pdf

IRT.0001.0002.7669 Wound / Skin Management Plan and Evaluation 8.6.18.pdf

IRT.0001.0002.7683 Wound / Skin Management Plan and Evaluation 8.7.18.pdf

IRT.0001.0002.7693 Wound / Skin Management Plan and Evaluation 9.1.18.pdf

IRT.0001.0002.7708 Wound / Skin Management Plan and Evaluation 9.2.18.pdf

IRT.0001.0002.7722 Wound / Skin Management Plan and Evaluation 9.3.18.pdf

131

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

IRT.0001.0002.7737 Wound / Skin Management Plan and Evaluation 9.5.18.pdf

IRT.0001.0002.7755 Wound / Skin Management Plan and Evaluation 9.6.18.pdf

IRT.0001.0002.7769 Wound / Skin Management Plan and Evaluation 9.7.18.pdf

IRT.0001.0002.7774 Wound / Skin Management Plan and Evaluation 9.8.18.pdf

IRT.0001.0002.7778 Wound / Skin Management Plan and Evaluation 9.9.18.pdf

IRT.0001.0002.7781 Wound / Skin Management Plan and Evaluation 31.3.18.pdf

IRT.0001.0002.7797 Wound / Skin Management Plan and Evaluation 1.1.18.pdf

IRT.0001.0002.7812 Wound / Skin Management Plan and Evaluation 10.1.18.pdf

IRT.0001.0002.7832 Wound / Skin Management Plan and Evaluation 13.11.18.pdf

IRT.0001.0002.7834 Wound / Skin Management Plan and Evaluation 14.7.18.pdf

IRT.0001.0002.7840 Wound / Skin Management Plan and Evaluation 16.1.18.pdf

IRT.0001.0002.7853 Wound / Skin Management Plan and Evaluation 17.1.18.pdf

IRT.0001.0002.7869 Wound / Skin Management Plan and Evaluation 2.2.18.pdf

IRT.0001.0002.7882 Wound / Skin Management Plan and Evaluation 20.1.18.pdf

IRT.0001.0002.7896 Wound / Skin Management Plan and Evaluation 21.1.18.pdf

IRT.0001.0002.7912 Wound / Skin Management Plan and Evaluation 26.1.18.pdf

IRT.0001.0002.7925 Wound / Skin Management Plan and Evaluation 3.2.18.pdf

IRT.0001.0002.7938 Wound / Skin Management Plan and Evaluation 31.1.18.pdf

IRT.0001.0002.7951 Wound / Skin Management Plan and Evaluation 4.4.18.pdf

IRT.0001.0002.7971 Wound / Skin Management Plan and Evaluation 9.1.18.pdf

IRT.0001.0002.7987 Wound / Skin Management Plan and Evaluation 9.2.18.pdf

IRT.0001.0002.8004 Wound / Skin Management Plan and Evaluation 1.6.18.pdf

IRT.0001.0002.8018 Wound / Skin Management Plan and Evaluation 1.7.18.pdf

IRT.0001.0002.8022 Wound / Skin Management Plan and Evaluation 10.4.18.pdf

IRT.0001.0002.8039 Wound / Skin Management Plan and Evaluation 10.5.18.pdf

IRT.0001.0002.8057 Wound / Skin Management Plan and Evaluation 12.5.18.pdf

IRT.0001.0002.8075 Wound / Skin Management Plan and Evaluation 12.7.18.pdf

IRT.0001.0002.8080 Wound / Skin Management Plan and Evaluation 13.3.18.pdf

IRT.0001.0002.8095 Wound / Skin Management Plan and Evaluation 13.5.18.pdf

IRT.0001.0002.8114 Wound / Skin Management Plan and Evaluation 13.6.18.pdf

IRT.0001.0002.8118 Wound / Skin Management Plan and Evaluation 13.7.18.pdf

IRT.0001.0002.8123 Wound / Skin Management Plan and Evaluation 14.4.18.pdf

IRT.0001.0002.8140 Wound / Skin Management Plan and Evaluation 14.8.18.pdf

IRT.0001.0002.8144 Wound / Skin Management Plan and Evaluation 15.4.18.pdf

IRT.0001.0002.8161 Wound / Skin Management Plan and Evaluation 15.5.18.pdf

IRT.0001.0002.8175 Wound / Skin Management Plan and Evaluation 15.6.18.pdf

IRT.0001.0002.8179 Wound / Skin Management Plan and Evaluation 15.7.18.pdf

IRT.0001.0002.8185 Wound / Skin Management Plan and Evaluation 16.5.18.pdf

IRT.0001.0002.8199 Wound / Skin Management Plan and Evaluation 17.7.18.pdf

IRT.0001.0002.8204 Wound / Skin Management Plan and Evaluation 18.3.18.pdf

IRT.0001.0002.8220 Wound / Skin Management Plan and Evaluation 18.4.18.pdf

132

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document Number Number

IRT.0001.0002.8237

Exhibit

Wound / Skin Management Plan and Evaluation 18.5.18.pdf

IRT.0001.0002.8251 Wound / Skin Management Plan and Evaluation 19.3.18.pdf

IRT.0001.0002.8268 Wound / Skin Management Plan and Evaluation 19.4.18.pdf

IRT.0001.0002.8285 Wound / Skin Management Plan and Evaluation 19.5.18.pdf

IRT.0001.0002.8300 Wound / Skin Management Plan and Evaluation 19.7.18.pdf

IRT.0001.0002.8305 Wound / Skin Management Plan and Evaluation 19.8.18.pdf

IRT.0001.0002.8309 Wound / Skin Management Plan and Evaluation 2.5.18.pdf

IRT.0001.0002.8327 Wound / Skin Management Plan and Evaluation 2.8.18.pdf

IRT.0001.0002.8332 Wound / Skin Management Plan and Evaluation 20.4.18.pdf

IRT.0001.0002.8349 Wound / Skin Management Plan and Evaluation 20.5.18.pdf

IRT.0001.0002.8364 Wound / Skin Management Plan and Evaluation 20.7.18.pdf

IRT.0001.0002.8369 Wound / Skin Management Plan and Evaluation 21.3.18.pdf

IRT.0001.0002.8385 Wound / Skin Management Plan and Evaluation 21.6.18.pdf

IRT.0001.0002.8389 Wound / Skin Management Plan and Evaluation 21.7.18.pdf

IRT.0001.0002.8394 Wound / Skin Management Plan and Evaluation 22.4.18.pdf

IRT.0001.0002.8411 Wound / Skin Management Plan and Evaluation 22.5.18.pdf

IRT.0001.0002.8426 Wound / Skin Management Plan and Evaluation 23.2.18.pdf

IRT.0001.0002.8440 Wound / Skin Management Plan and Evaluation 23.3.18.pdf

IRT.0001.0002.8456 Wound / Skin Management Plan and Evaluation 23.6.18.pdf

IRT.0001.0002.8460 Wound / Skin Management Plan and Evaluation 24.4.18.pdf

IRT.0001.0002.8493 Wound / Skin Management Plan and Evaluation 25.3.18.pdf

IRT.0001.0002.8509 Wound / Skin Management Plan and Evaluation 25.7.18.pdf

IRT.0001.0002.8514 Wound / Skin Management Plan and Evaluation 26.2.18.pdf

IRT.0001.0002.8528 Wound / Skin Management Plan and Evaluation 26.5.18.pdf

IRT.0001.0002.8544 Wound / Skin Management Plan and Evaluation 26.6.18.pdf

IRT.0001.0002.8548 Wound / Skin Management Plan and Evaluation 27.3.18.pdf

IRT.0001.0002.8565 Wound / Skin Management Plan and Evaluation 27.4.18.pdf

IRT.0001.0002.8582 Wound / Skin Management Plan and Evaluation 27.5.18.pdf

IRT.0001.0002.8598 Wound / Skin Management Plan and Evaluation 27.6.18.pdf

IRT.0001.0002.8602 Wound / Skin Management Plan and Evaluation 27.7.18.pdf

IRT.0001.0002.8609 Wound / Skin Management Plan and Evaluation 28.3.18.pdf

IRT.0001.0002.8625 Wound / Skin Management Plan and Evaluation 28.4.18.pdf

IRT.0001.0002.8643 Wound / Skin Management Plan and Evaluation 28.5.18.pdf

IRT.0001.0002.8659 Wound / Skin Management Plan and Evaluation 29.6.18.pdf

IRT.0001.0002.8663 Wound / Skin Management Plan and Evaluation 29.7.18.pdf

IRT.0001.0002.8668 Wound / Skin Management Plan and Evaluation 3.1.18.pdf

IRT.0001.0002.8683 Wound / Skin Management Plan and Evaluation 3.3.18.pdf

IRT.0001.0002.8698 Wound / Skin Management Plan and Evaluation 3.6.18.pdf

IRT.0001.0002.8712 Wound / Skin Management Plan and Evaluation 3.7.18.pdf

IRT.0001.0002.8716 Wound / Skin Management Plan and Evaluation 3.8.18.pdf

IRT.0001.0002.8721 Wound / Skin Management Plan and Evaluation 30.4.18.pdf

133

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

IRT.0001.0002.8739 Wound / Skin Management Plan and Evaluation 31.7.18.pdf

IRT.0001.0002.8744 Wound / Skin Management Plan and Evaluation 4.1.18.pdf

IRT.0001.0002.8759 Wound / Skin Management Plan and Evaluation 4.5.18.pdf

IRT.0001.0002.8777 Wound / Skin Management Plan and Evaluation 4.6.18.pdf

IRT.0001.0002.8795 Wound / Skin Management Plan and Evaluation 5.4.18.pdf

IRT.0001.0002.8812 Wound / Skin Management Plan and Evaluation 5.7.18.pdf

IRT.0001.0002.8817 Wound / Skin Management Plan and Evaluation 6.5.18.pdf

IRT.0001.0002.8835 Wound / Skin Management Plan and Evaluation 6.6.18.pdf

IRT.0001.0002.8849 Wound / Skin Management Plan and Evaluation 7.2.18.pdf

IRT.0001.0002.8862 Wound / Skin Management Plan and Evaluation 7.3.18.pdf

IRT.0001.0002.8876 Wound / Skin Management Plan and Evaluation 7.4.18.pdf

IRT.0001.0002.8893 Wound / Skin Management Plan and Evaluation 7.6.18.pdf

IRT.0001.0002.8907 Wound / Skin Management Plan and Evaluation 7.7.18.pdf

IRT.0001.0002.8915 Wound / Skin Management Plan and Evaluation 8.5.18.pdf

IRT.0001.0002.8933 Wound / Skin Management Plan and Evaluation 8.6.18.pdf

IRT.0001.0002.8947 Wound / Skin Management Plan and Evaluation 8.8.18.pdf

IRT.0001.0002.8952 Wound / Skin Management Plan and Evaluation 9.3.18.pdf

IRT.0001.0002.8967 Wound / Skin Management Plan and Evaluation 9.6.18.pdf

IRT.0001.0002.8980 Wound / Skin Management Plan and Evaluation 9.7.18.pdf

IRT.0001.0002.8985 Wound / Skin Management Plan and Evaluation 10.1.18.pdf

IRT.0001.0002.9000 Wound / Skin Management Plan and Evaluation 16.1.18.pdf

IRT.0001.0002.9013 Wound / Skin Management Plan and Evaluation 17.1.18.pdf

IRT.0001.0002.9030 Wound / Skin Management Plan and Evaluation 8.5.18.pdf

IRT.0001.0002.9048 Wound / Skin Management Plan and Evaluation 9.1.18.pdf

IRT.0001.0002.9067 Wound / Skin Management Plan and Evaluation 1.7.18.pdf

IRT.0001.0002.9071 Wound / Skin Management Plan and Evaluation 10.5.18.pdf

IRT.0001.0002.9092 Wound / Skin Management Plan and Evaluation 13.3.18.pdf

IRT.0001.0002.9107 Wound / Skin Management Plan and Evaluation 13.5.18.pdf

IRT.0001.0002.9121 Wound / Skin Management Plan and Evaluation 13.7.18.pdf

IRT.0001.0002.9126 Wound / Skin Management Plan and Evaluation 15.7.18.pdf

IRT.0001.0002.9132 Wound / Skin Management Plan and Evaluation 16.5.18.pdf

IRT.0001.0002.9146 Wound / Skin Management Plan and Evaluation 18.3.18.pdf

IRT.0001.0002.9162 Wound / Skin Management Plan and Evaluation 19.3.18.pdf

IRT.0001.0002.9179 Wound / Skin Management Plan and Evaluation 20.5.18.pdf

IRT.0001.0002.9194 Wound / Skin Management Plan and Evaluation 20.7.18.pdf

IRT.0001.0002.9199 Wound / Skin Management Plan and Evaluation 22.4.18.pdf

IRT.0001.0002.9216 Wound / Skin Management Plan and Evaluation 22.5.18.pdf

IRT.0001.0002.9232 Wound / Skin Management Plan and Evaluation 22.6.18.pdf

IRT.0001.0002.9236 Wound / Skin Management Plan and Evaluation 23.2.18.pdf

IRT.0001.0002.9250 Wound / Skin Management Plan and Evaluation 27.5.18.pdf

IRT.0001.0002.9266 Wound / Skin Management Plan and Evaluation 27.7.18.pdf

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

134

Exhibit Document Number Number

Exhibit

IRT.0001.0002.9271 Wound / Skin Management Plan and Evaluation 29.6.18.pdf

IRT.0001.0002.9275 Wound / Skin Management Plan and Evaluation 4.1.18.pdf

IRT.0001.0002.9290 Wound / Skin Management Plan and Evaluation 4.5.18.pdf

IRT.0001.0002.9308 Wound / Skin Management Plan and Evaluation 5.4.18.pdf

IRT.0001.0002.9325 Wound / Skin Management Plan and Evaluation 7.4.18.pdf

IRT.0001.0002.9342 Wound / Skin Management Plan and Evaluation 7.6.18.pdf

IRT.0001.0002.9356 Wound / Skin Management Plan and Evaluation 8.6.18.pdf

IRT.0001.0002.9370 Wound / Skin Management Plan and Evaluation 9.3.18.pdf

IRT.0001.0002.9385 Wound / Skin Management Plan and Evaluation 9.7.18.pdf

IRT.0001.0002.9390 Wound / Skin Management Plan and Evaluation 10.1.18.pdf

IRT.0001.0002.9403 Wound / Skin Management Plan and Evaluation 9.1.18.pdf

IRT.0001.0002.9420 Wound / Skin Management Plan and Evaluation 13.5.18.pdf

IRT.0001.0002.9434 Wound / Skin Management Plan and Evaluation 13.7.18.pdf

IRT.0001.0002.9440 Wound / Skin Management Plan and Evaluation 16.5.18.pdf

IRT.0001.0002.9454 Wound / Skin Management Plan and Evaluation 23.2.18.pdf

IRT.0001.0002.9468 Wound / Skin Management Plan and Evaluation 27.7.18.pdf

IRT.0001.0002.9473 Wound / Skin Management Plan and Evaluation 4.1.18.pdf

IRT.0001.0002.9488 Wound / Skin Management Plan and Evaluation 4.5.18.pdf

IRT.0001.0002.9506 Wound / Skin Management Plan and Evaluation 8.6.18.pdf

IRT.0001.0002.9520 Wound / Skin Management Plan and Evaluation5 16.5.18.pdf

IRT.0001.0002.9534 Wound / Skin Management Plan and Evaluation5 23.2.18.pdf

IRT.0001.0002.9548 Wound / Skin Management Plan and Evaluation6 16.5.18.pdf

IRT.0001.0002.9562 Wound / Skin Management Plan and Evaluation6 23.2.18.pdf

IRT.0001.0002.9576 Shirley Fowler Progress Notes 1 January 2017 - 30 June 2017.docx

IRT.0001.0002.9675 Shirley Fowler Progress Notes 1 January 2018 - 30 June 2018.docx

IRT.0001.0003.0001 Shirley Fowler Progress Notes 1 July 2017 - 31 December 2017.docx

IRT.0001.0003.0175 Shirley Fowler Progress Notes 1 July 2018 - 1 January 2019. docx

IRT.0001.0003.0289 Shirley Fowler Progress Notes 1 June 2016 - 31 December 2016. docx

IRT.0001.0003.0854 C-12 Behavioural Management.pdf

IRT.0001.0003.0858 C-32 Emotional Support.pdf

IRT.0001.0003.0861 C-7 Falls Management.pdf

IRT.0001.0003.0865 CC-10B Reviewing a Deteriorating Resident (Clinical Assessment).pdf

IRT.0001.0003.0866 CC-11 Palliative Care Management.pdf

IRT.0001.0003.0870 CC-3 Wound Management.pdf

IRT.0001.0003.0886 1.15 Specialised Nursing Care Needs.PDF

IRT.0001.0003.0890 1.17 MEDICATION MANAGEMENT (CARE CENTRES).PDF

IRT.0001.0003.0943 1.20 Pain Management.PDF

IRT.0001.0003.0952 1.21 Palliative Care.PDF

IRT.0001.0003.0960 1.22 Nutrition and Hydration.PDF

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

135

IRT.0001.0003.0986 1.23.01 Skin Care Management Procedure.PDF

IRT.0001.0003.1000 1.24 Foot Care.PDF

IRT.0001.0003.1002 1.28 Mobility Dexterity Rehabilitation.PDF

IRT.0001.0003.1011 1.57 Clinical Risk and Deterioration.PDF

IRT.0001.0003.1020 1.57.01 - Falls Management Immediate Response.PDF

IRT.0001.0003.1028 1.57.02 Nutrition and Hydration Procedure.PDF

IRT.0001.0003.1052 OP 1.57 Fall Management Policy.PDF

IRT.0001.0003.1324 Response - IRT William Beach Gardens.pdf

IRT.0001.0003.1402 S18-00XXX IRT WBG ACC Response 07092017.pdf

IRT.0001.0003.1479 Email CASE ID: S18/00XXXX

IRT.0001.0003.1567 CASE ID S18 00XXXX Response.docx

IRT.0001.0003.1572 Email Case ID S1800XXXX

IRT.0001.0003.1573 Case ID S1800XXXX Response to clinical concerns.docx

IRT.0001.0003.1607 Template 10c - Finalisation Letter (Provider) S18 00XXXX.pdf

IRT.0001.0003.1627 IRT Report - Template.docx

IRT.0001.0003.1641 Incidential & “One to One” Training Log re wounds complaint

IRT.0001.0003.1911 Email RE: CASE ID: S18/00XXXX [SEC=UNCLASSIFIED]

IRT.0001.0003.1954 OP 1 14 Clinical Care.pdf

IRT.0001.0003.1981 Email RE: Case ID S1800XXXX [SEC=UNCLASSIFIED]

IRT.0001.0003.1985 S18 00XXXX - Notice of Intention to Issue Directions.pdf

IRT.0001.0003.2007 IRT WBG Response to Aged Care Complaints Commissioner

IRT.0001.0003.2348 Re-accreditation Decision and statement of reasons for IRT William Beach Gardens

IRT.0001.0003.2560 Goals of Care - Care, Lifestyle and Podiatry

IRT.0001.0003.2609 9.0 Dietary Supplement List (10).pdf

IRT.0001.0003.2616 3.0 Unresolved Wounds (37).pdf

IRT.0001.0003.2764 5.0 Case Conference (2).pdf

IRT.0001.0003.2818 5.0ComplexHealthCare WBG 271017.pdf

IRT.0001.0004.0193 Internal IRT email re IRT ACC Financial Report Oct18

IRT.0001.0004.4485 Email RE: Shirley Fowler

IRT.0001.0004.4495 Email RE: complaint

IRT.0001.0017.5540 Email FW: Dietitian

IRT.0001.0017.5586 Emails between L Fowler and K Taylor re Staffing levels

IRT.0001.0022.3070 IRT email re Leecare Webstercare Synchronisation Notification (All)

IRT.0001.0022.4030 patient care concern

IRT.0001.0022.4031 Email SD Fowler

IRT.0001.0022.4038 Email SD Fowler

IRT.0001.0022.4039 Aug 2015.JPG

IRT.0001.0022.4040 Aug 2015 3.JPG

IRT.0001.0022.4041 Aug 2015 4.JPG

IRT.0001.0022.4068 Email Shirley Fowler

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

136

Exhibit Document Number Number

Exhibit

IRT.0001.0022.4069 Emails between L Fowler and K Perry re Maggie’s mission: why we need to give food more thought

IRT.0001.0022.4085 Email from L Fowler to K Perry re Shirley Fowler

IRT.0001.0022.4090 Emails between L Fowler and K Perry re Lactose free supplies

IRT.0001.0022.4091 Fwd: Lyndal Fowler

IRT.0001.0022.4131 Emails between L Fowler and K Perry re Shirley Fowler

IRT.0001.0022.4133 Emails between L Fowler and K Perry re Shirley Fowler

IRT.0001.0022.4141 Email from L Fowler to K Perry re Best Practice Food & Nutrition for Aged Care

IRT.0001.0022.4142 Email from L Fowler to K Perry re Shirley Fowler

IRT.0001.0022.4146 Emails between K Perry and L Fowler re Update

IRT.0001.0022.4148 Emails between L Fowler and K Perry re Lactose free supplies

IRT.0001.0022.4150 Email from L Fowler to K Perry re Lactose free supplies

IRT.0001.0022.4153 Email from L Fowler to K Perry re Shirley Fowler

IRT.0001.0022.4156 Email from L Fowler to K Perry re Lactose free options

IRT.0001.0022.4177 RE: Shirley Fowler

IRT.0001.0022.4179 RE: Puree meal

IRT.0001.0022.4181 RE: Shirley Fowler

IRT.0001.0022.4186 RE: Shirley Fowler

IRT.0001.0022.4191 RE: Shirley Fowler

IRT.0001.0022.4192 RE: RE: Shirley Fowler

IRT.0001.0022.4194 Email RE: Shirley Fowler

IRT.0001.0022.4197 Email RE: Update

IRT.0001.0022.4201 RE: Shirley Fowler

IRT.0001.0022.4202 RE: Shirley Fowler

IRT.0001.0022.4205 RE: Shirley Fowler

IRT.0001.0022.4206 RE: Lactose free options

IRT.0001.0022.4209 RE: System failure

IRT.0001.0022.4213 Mobile Dental Service

IRT.0001.0022.4216 FW: Mobile Dental Service

IRT.0001.0022.4230 FW: Maggie’s mission: why we need to give food more thought

IRT.0001.0022.4237 FW: Mince Moist meal

IRT.0001.0022.4247 Lactose free diet

IRT.0001.0022.4248 RE: Meals for Shirley

IRT.0001.0022.4250 Shirley Fowler

IRT.0001.0022.4268 RE: SD Fowler

IRT.0001.0022.4286 RE: Shirley Fowler

IRT.0001.0022.4291 RE: SD Fowler

IRT.0001.0022.4296 RE: SD Fowler

IRT.0001.0022.4301 FW: Spark of Life Certified Club Facilitator Course

IRT.0001.0022.4315 FW: Shirley Fowler

IRT.0001.0022.4342 Email re tears and toe nails

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

137

IRT.0001.0022.4482 FW: Sling for hoist

IRT.0001.0022.4511 RE: Shirley Fowler

IRT.0001.0022.4579 Email re Total Mobility and sling

IRT.0001.0022.4595 RE: Foot protectors

IRT.0001.0022.4597 RE: Maggie’s mission: why we need to give food more thought

IRT.0001.0022.4604 FW: Shirley Fowler

IRT.0001.0022.4609 RE: Shirley Fowler

IRT.0001.0022.4610 Shirley Fowler

IRT.0001.0022.4619 RE: Lactose free options

IRT.0001.0022.4627 RE: Shirley Fowler

IRT.0001.0022.4637 RE: Shirley Fowler

IRT.0001.0022.7049 IRT Memo re: Resident Movement Notice

IRT.0001.0022.7058 shirley Fowler

IRT.0001.0022.8304 Re: podiatrist visits

IRT.0001.0023.3268 RE: Shirley Fowler

IRT.0001.0036.3767 RE: SD Fowler

IRT.0001.0036.3783 RE: Dental Appointment

IRT.0001.0036.9256 Re: Shirley Fowler

IRT.0001.0041.3443 Feedback on the ACFI for Shirley Fowler follows:

IRT.0001.0041.3451 Shirley Fowler

IRT.0001.0041.3452 Oct 2015 014.JPG

IRT.0001.0041.3453 Oct 2015 015.JPG

IRT.0001.0041.3454 Oct 2015 018.JPG

IRT.0001.0041.3467 Fwd: End of Life Plan for Shirley Fowler - please fwd. to Sam

IRT.0001.0041.3495 Shirley Fowler

IRT.0001.0041.3507 Re: Shirley Fowler

IRT.0001.0041.3512 RE: Shirley Fowler

IRT.0001.0041.3527 Re: Shirley Fowler

IRT.0001.0041.3545 RE: Shirley Fowler

IRT.0001.0041.3547 Email Shirley Fowler

IRT.0001.0041.3548 RE: Shirley Fowler

IRT.0001.0041.3554 ATT Dr Robert Bird

IRT.0001.0041.3563 Email

IRT.0001.0041.3564 20180613_164503.jpg

IRT.0001.0041.3577 RE: Shirley Fowler

IRT.0001.0041.3602 Quote for sling

IRT.0001.0041.3603 Quote for sling

IRT.0001.0041.3619 Air chairs

IRT.0001.0041.5754 Email to Kristy Taylor re handover

IRT.0001.0042.4546 William Beach Gardens Reaccreditation Selfassessment Tool - 2017.pdf IRT.0001.0048.8510 0.3 ALLERGIES REPORT WBG 1.docx

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

138

Exhibit Document Number Number

Exhibit

IRT.0001.0048.9119 20180619 - Fact Finding Meeting - Shahab Parsa.docx

IRT.0001.0049.6452 FALLS JUNE - NOVEMBER 2016.docx

IRT.0001.0051.8796 WBG - Comments and Complaints Register 2018 - Copy.xls

IRT.0001.0051.8797 WBG 14.12.17.docx

IRT.0001.0054.3356 Audit WBG week commencing 5.02.18.docx

IRT.0001.0054.3428 Note re L Fowler administering 02 to another resident

IRT.0001.0055.3417 Audit WBG Week commencing 13.11.17 (3).docx

IRT.0001.0058.0408 FALLS REVIEW REPORT with vitals (3).pdf

IRT.0001.0058.3006 QA Audit Feedback - IRT WBG.docx

IRT.0001.0058.6083 Audit WBG week commencing 22.01.18 (Autosaved).docx

IRT.0001.0063.5607 IRT OP 1.29 Oral and Dental Care

IRT.0001.0063.5631 IRT OP 1.39 Leisure Interests and Activities

IRT.0001.0066.0004 IRT OP 1.16 Other Health & Related Services

IRT.0001.0066.0008 IRT OP 1.25 Continence Management

IRT.0001.0066.0015 IRT OP 1.26 Behavioural Management

IRT.0001.0066.0032 IRT OP 1.27 Restraint

IRT.0001.0066.0051 IRT OP 1.30 Sensory Loss

IRT.0001.0066.0063 IRT OP 1.49 Catering

IRT.0001.0066.0094 IRT OP 3.10 Critical Incident Management Plan (New Template). docx

IRT.0001.0066.0137 IRT OP 1.46 Ageing in Place.PDF

IRT.0001.0066.0199 IRT ST 3.10 Critical Incident Management Plan ver 1 3 May 2015.PDF

IRT.0001.0067.0010 1.12.17 - Clinical Care Team Meeting Minutes

IRT.0001.0067.0021 4.5.18 - Clinical Care Team Meeting Minutes

IRT.0001.0067.0025 4.12.17 - Clinical Care Team Meeting Minutes

IRT.0001.0068.0001 Progress Notes Shirley FOWLER Contractures 27/10/2016 - 10/04/2017

IRT.0001.0068.0016 Physiotherapy Assessment / Plan 290716

IRT.0001.0068.0021 Physiotherapy Assessment _ Plan 290716.pdf

IRT.0001.0068.0026 Physiotherapy Assessment _ Plan 181016.pdf

IRT.0001.0068.0038 0.7 Functional Assessment 091116.pdf

IRT.0001.0068.0067 0.25 Pain Management Record 010716-011116.pdf

IRT.0001.0068.0070 Progress Notes Shirley FOWLER Mobility 010716-011116.docx

IRT.0001.0068.0099 0.3 Falls and Other Risks Shirley FOWLER 18072016.pdf

IRT.0001.0068.0127 0.11 Functional Assessment Shirley FOWLER 02072016.pdf

IRT.0001.0068.0141 0.1 Incident ID No 7196889 Created 070716.pdf

IRT.0001.0068.0143 0.2 Incident ID No 7335316 Created 140716.pdf

IRT.0001.0068.0145 0.3 Incident ID No 7396230 Created 170716.pdf

IRT.0001.0068.0147 0.4 Incident ID No 8652106 Created 150916.pdf

IRT.0001.0068.0149 0.6 Incident ID No 9075960 Created 051016.pdf

IRT.0001.0068.0151 0.7 Incident ID No 9185613 Created 101016.pdf

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

139

IRT.0001.0068.0154 0.28 Physical - Self Care Ability _ Preferences 020716.pdf

IRT.0001.0068.0159 Incident ID No 25453375 Created 040918.pdf

IRT.0001.0068.0161 Incident ID No 25594926 Created 090918.pdf

IRT.0001.0068.0163 Physiotherapy_Occupational Therapy Assessment_Plan 130818.pdf

IRT.0001.0068.0168 Progress Notes Mobility

IRT.0001.0068.0174 0. Incident ID No 19477039 Created 010118.pdf

IRT.0001.0068.0176 0. Incident ID No 9008483 Created 021016.pdf

IRT.0001.0068.0178 Progress Notes PA & Wound Mx 010916-311017.docx

IRT.0001.0068.0203 0.2 Progress Notes PA & Wound Mx 011117 - 280218.docx

IRT.0001.0068.0216 0.3 Progress Notes PA & Wound Mx 010318-300518.docx

IRT.0001.0068.0273 8 Skin Assessment 250417.pdf

IRT.0001.0068.0277 Infection ID No 16791700 Created 090917.pdf

IRT.0001.0068.0278 Infection ID No 17218340 Created 270917.pdf

IRT.0001.0068.0280 Infection ID No 17963353 Created 281017.pdf

IRT.0001.0068.0283 Infection ID No 21511638 Created 280318.pdf

IRT.0001.0068.0567 Wound _ Skin Management Plan and Evaluation(148).pdf

IRT.0001.0068.1781 Wound _ Skin Management Plan and Evaluation(264).pdf

IRT.0001.0068.2087 Wound _ Skin Management Plan and Evaluation(288).pdf

IRT.0001.0068.3918 Wound _ Skin Management Plan and Evaluation(414).pdf

IRT.0001.0068.4615 Wound _ Skin Management Plan and Evaluation(455).pdf

IRT.0001.0068.6045 Wound _ Skin Management Plan and Evaluation(550).pdf

IRT.0001.0068.6226 Wound _ Skin Management Plan and Evaluation(590).pdf

IRT.0001.0068.6459 Wound _ Skin Management Plan and Evaluation(633).pdf

IRT.0001.0068.6480 Wound _ Skin Management Plan and Evaluation(638).pdf

IRT.0001.0069.0113 1.0Physiotherapy Assessment _ Plan 021015.pdf

IRT.0001.0069.0122 1.11Physiotherapy_Occupational Therapy Assessment_Plan 180119.pdf

IRT.0001.0069.0127 1.1Physiotherapy Assessment _ Plan 301215.pdf

IRT.0001.0069.0131 1.4Physiotherapy Assessment _ Plan 131216.pdf

IRT.0001.0069.0137 1.5Physiotherapy Assessment _ Plan 030817.pdf

IRT.0001.0069.0143 1.6Physiotherapy Assessment _ Plan 080817.pdf

IRT.0001.0069.0149 1.7Physiotherapy Assessment _ Plan 301117.pdf

IRT.0001.0069.0155 1.8Physiotherapy Assessment _ Plan 211217.pdf

IRT.0001.0069.0161 1.9Physiotherapy_Occupational Therapy Assessment_Plan 180418.pdf

IRT.0001.0069.0166 2.0Functional Assessment 150415.pdf

IRT.0001.0069.0185 2.1Functional Assessment 021015.pdf

IRT.0001.0069.0196 2.22Functional Assessment 070219.pdf

IRT.0001.0069.0200 2.2Functional Assessment 151215.pdf

IRT.0001.0069.0117 1.10Physiotherapy_Occupational Therapy Assessment_Plan 130818.pdf

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

140

Exhibit Document Number Number

Exhibit

IRT.0001.0069.0203 2.3Functional Assessment 220316.pdf

IRT.0001.0069.0207 2.4Functional Assessment 260316.pdf

IRT.0001.0069.0211 2.5Functional Assessment 010416.pdf

IRT.0001.0069.0219 Progress Notes Contractures 010716-310718.docx

IRT.0001.0069.0228 Progress Notes Contractures 010818-010119.docx

IRT.0001.0069.0231 0.0Care Evaluation 221215.pdf

IRT.0001.0069.0236 0.10Care Evaluation (New Format from this date) 260418.pdf

IRT.0001.0069.0242 0.11Care Evaluation 170818.pdf

IRT.0001.0069.0247 0.12Care Evaluation 201218.pdf

IRT.0001.0069.0252 0.13Care Evaluation 270419.pdf

IRT.0001.0069.0258 0.1Care Evaluation 300316.pdf

IRT.0001.0069.0264 0.2Care Evaluation 040716.pdf

IRT.0001.0069.0342 0.1Dietary Details 150415.pdf

IRT.0001.0069.0359 0.25Dietary Details 170219.pdf

IRT.0001.0069.0362 0.26Dietary Details 130419.pdf

IRT.0001.0069.0365 0.3Dietary Details 220316 (2).pdf

IRT.0001.0069.0380 1.0Progress Notes Dietary Needs 010715-311015.docx

IRT.0001.0069.0389 1.10Progress Notes Dietary Needs 011118-280219.docx

IRT.0001.0069.0395 1.11Progress Notes Dietary Needs 010319-010619.docx

IRT.0001.0069.0404 1.1Progress Notes Dietary Needs 011115-290216.docx

IRT.0001.0069.0409 1.2Progress Notes Dietary Needs 010316-300616.docx

IRT.0001.0069.0417 1.3Progress Notes Dietary Needs 010716-311016.docx

IRT.0001.0069.0419 1.4Progress Notes Dietary Needs 011116-280217.docx

IRT.0001.0069.0423 1.5Progress Notes Dietary Needs 010317-300617.docx

IRT.0001.0069.0445 1.6Progress Notes Dietary Needs 010717-311017.docx

IRT.0001.0069.0458 1.7Progress Notes Dietary Needs 011117-280218.docx

IRT.0001.0069.0468 1.8Progress Notes Dietary Needs 010318-300618.docx

IRT.0001.0069.0476 1.9Progress Notes Dietary Needs 010718-311018.docx

IRT.0001.0069.0481 2.0Nutrition Assessment 150419.pdf

IRT.0001.0069.0483 2.10Nutrition Assessment 130419.pdf

IRT.0001.0069.0486 2.1Nutrition Assessment 220316.pdf

IRT.0001.0069.0511 Med Chart Notes 010815.docx

IRT.0001.0069.0512 Notes attached to Point 6.docx

IRT.0001.0069.0513 Weight Record 150415-080619.pdf

IRT.0001.0069.0520 IRT Integrated Progress Notes - GP

IRT.0001.0069.0522 Physiotherapy Assessment _ Plan 8 August 17.pdf

IRT.0001.0069.0528 Progress Notes 08116-161116.docx

IRT.0001.0069.0534 Progress Notes 4 AUg 17 re physio referral.pdf

IRT.0001.0069.0539 Resident Client Aggression Incident Report 040813.docx

IRT.0001.0069.0540 Resident Client Aggression Incident Report 050813.docx

IRT.0001.0069.0541 S FOWLER CRISIS ORDERS-16062017172252.jpg

141

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

IRT.0001.0069.0542 S Fowler Resident of the Day Progress Notes.pdf

IRT.0001.0069.0561 Shirley FOWLER Platinum 5.0 File Front Page.docx

IRT.0001.0069.0562 Weight and Vital Signs_ Urinalysis 100716-111016.pdf

IRT.0001.0069.0563 Z SCANS_pall care-fowler-31.5.17-31052017170516.jpg

IRT.0001.0069.0564 Doctor & Health Specialist Visit Record 260218-190619.pdf

IRT.0001.0069.0567 GP Contact 010715-300616.docx

IRT.0001.0069.0574 GP contact 010716-300617.docx

IRT.0001.0069.0585 GP Contact 010717-3011018.docx

IRT.0001.0069.0603 GP Contact 051218-010619.docx

IRT.0001.0069.0606 GP Vital Signs Monitoring Directive 100419.pdf

IRT.0001.0069.0607 S Fowler Repositioning Record 1 July 2016 to 1 January 2019.pdf

IRT.0001.0070.0001 1.33 Emotional Support.PDF

IRT.0001.0070.0014 1.54 Non IRT Food Policy.PDF

IRT.0001.0070.0022 OP 1.42 Choice and Decision Making.pdf

IRT.0001.0070.0026 OP1.35 Independence.pdf

IRT.0001.0071.0001 Daily Record_ Pain 1 July 16 to 1 jan 19.pdf

IRT.0001.0071.0024 Infection report for 27 oct 17.pdf

IRT.0001.0071.0025 Infection report form 14 Nov 17.pdf

IRT.0001.0071.0026 Initial interview - food assessment.pdf

IRT.0001.0071.0038 Z READ ONLY Behaviour Evaluation 5 June 2017.pdf

IRT.0001.0071.0041 Z READ ONLY Physiotherapy Assessment _ Plan 30 Nov 17.pdf

IRT.0001.0072.0001 1.37 Privacy and Dignity Policy

IRT.0001.0072.0035 Communication - training record_AU_Active01_905033053_1.xlsx

IRT.0001.0072.0036 Daily Record_ Behaviour 010716-011116.pdf

IRT.0001.0072.0037 Daily Record_ Bowel Chart 010716-011116.pdf

IRT.0001.0072.0049 Daily Record_ Hygiene _ Care 010716-011116.pdf

IRT.0001.0072.0054 Falls Management - training record_AU_Active01_905033078_1.xls

IRT.0001.0072.0055 2017 William Beach Gardens Education Calendar.xlsx

IRT.0001.0072.0078 WBG Education Calendar2018.xlsx

IRT.0001.0072.0079 WBG_education calendar_2019_promo version.xlsx

IRT.0001.0072.0080 Wound Photos in Chronological Order.docx

IRT.0001.0072.0315 Nutrition and Hydration - training record_AU_ Active01_905033017_1.xlsx

IRT.0001.0072.0316 Skin Care - training record_AU_Active01_905033074_1.xlsx

IRT.0001.0072.0317 WBG Map.pdf

IRT.0001.0072.0321 Wound Care - training record_AU_Active01_905033060_1.xlsx

IRT.0002.0001.0010 Annexure A - Number of direct care staff at IRT Williams Beach Gardens as at 1 November 2017.pdf

LFO.0001.0001.0003 L foot bunion area 18 March 2018

LFO.0001.0001.0005 L foot Nov 29 2017

LFO.0001.0001.0008 Positioned with booties to protect feet

LFO.0001.0001.0011 R foot 3 Dec 2017

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Exhibit Document

Exhibit

Number Number

LFO.0001.0001.0013 R foot bunion area 29 November 2017 and below Dec 2017 showing necrotic

LFO.0001.0001.0019 Severe contracture R leg (2)

LFO.0001.0001.0020 Severe contracture R leg

LFO.0001.0001.0022 Photograph (Shirley) February/March 2015

LFO.0001.0001.0027 Photograph (Shirley with dog)

IRT.0001.0002.0592 Acute Care Needs _ Nursing Care Plan Shirley Fowler 15th June 2017.rtf

IRT.0001.0002.2920 Pain Assessment _ Management Plan Shirley Fowler 16th June 2017.rtf

DHC.0001.0001.0001 Attachment 1 - Proposal by Dapto Healthcare Pty Ltd to Trial a Variation in Aged Health Care Service Del

DHC.0001.0001.0004 Attachment 2 - Royal Commission into Aged Care Quality and Safety - The Key Clinical Issues

DHC.0001.0001.0008 Attachment 3 - Progress Notes for Shirley Fowler DHC.0001.0001.0017 Attachment 4 - Certificates

DHC.0001.0001.0031 Attachment 5 - Dapto Healthcare Nursing Home Attendance Roster

DHC.0001.0001.0043 Attachment 6 - Progress Notes Selection Criteria

IRT.0001.0002.1624 Daily Record_ Daily Repositioning Shirley Fowler 1 January 2017 to 1 January 2018.pdf

IRT.0001.0002.1714 Daily Record_ Daily Repositioning Shirley Fowler 1 January 2018 to 1 January 2019.pdf

IRT.0001.0002.1883 Daily Record_ Daily Repositioning Shirley Fowler 1 July 2016 to 1 January 17.pdf

IRT.0001.0003.2026 Daily Repositioning.pdf

IRT.0001.0041.4203 Daily Repositioning.pdf

IRT.0001.0041.3464 Fwd: PT meeting

IRT.0001.0003.1924 RE: Case Id: S18/00XXXX [SEC=UNCLASSIFIED]

DHC.0002.0001.0117 Email from L Fowler to Dapto Healthcare

DHC.0002.0001.0001 Discharge Referral

DHC.0002.0001.0003 Discharge Referral

DHC.0002.0001.0005 Dapto Healthcare Patient Registration Form

DHC.0002.0001.0032 Discharge Referral

DHC.0002.0001.0034 Fax from IRT to Dapto Healthcare

DHC.0002.0001.0035 Discharge Referral

DHC.0002.0001.0037 Discharge Referral

DHC.0002.0001.0039 Fax from IRT to Dapto Healthcare

DHC.0002.0001.0041 Fax from IRT to Dapto Healthcare

DHC.0002.0001.0045 Referral from IRT to Dapto Healthcare

DHC.0002.0001.0047 General Referral

DHC.0002.0001.0049 Fax from IRT to Dapto Healthcare

DHC.0002.0001.0070 Fax from IRT to Dapto Healthcare

143

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

DHC.0002.0001.0071 Fax from IRT to Dapto Healthcare

DHC.0002.0001.0074 Fax from IRT to Dapto Healthcare

DHC.0002.0001.0078 Fax from Podiatrist to Dapto Healthcare

DHC.0002.0001.0081 Admission notification to GP

DHC.0002.0001.0084 Palliative Care Discharge Referral

DHC.0002.0001.0090 Letter from psychiatrist to Dapto Healthcare

DHC.0002.0001.0093 General Referral

DHC.0002.0001.0096 Letter from plastic surgeon to Dapto Healthcare

DHC.0002.0001.0100 Letter from Geriatrician to Dapto Healthcare

DHC.0002.0001.0105 General Referral

DHC.0002.0001.0109 General Referral

DHC.0002.0001.0112 Fax from IRT to Dapto Healthcare

DHC.0002.0001.0117 Email from L Fowler to Dapto Healthcare

DHC.0002.0001.0120 Discharge Referral

DHC.0002.0001.0123 General Referral

DHC.0002.0001.0127 General Referral

DHC.0002.0001.0129 Fax from IRT to Dapto Healthcare

DHC.0002.0001.0157 Residential Medication Management Review

DHC.0002.0001.0160 General Referral

DHC.0002.0001.0163 Discharge notification to GP

DHC.0002.0001.0164 Discharge Referral

DHC.0002.0001.0166 General Referral DHC.0002.0001.0168 Discharge notification to GP

DHC.0002.0001.0170 Letter from Dapto Healthcare to Doctor

DHC.0002.0001.0171 Letter from Dapto Healthcare to Doctor

DHC.0002.0001.0077 Admission notification to GP

DHC.0002.0001.0079 Discharge Referral

DHC.0002.0001.0082 Histopathology Report

DHC.0002.0001.0085 Fax from IRT to Dapto Healthcare

DHC.0002.0001.0092 Pathology report

DHC.0002.0001.0095 Letter from psychiatrist to Dapto Healthcare

DHC.0002.0001.0097 Fax from IRT to Dapto Healthcare

DHC.0002.0001.0102 Letter from Geriatrician to Dapto Healthcare

DHC.0002.0001.0107 Podiatrist referral form

DHC.0002.0001.0111 Doctor visit record

DHC.0002.0001.0114 Fax from IRT to Dapto Healthcare

DHC.0002.0001.0118 General Referral

DHC.0002.0001.0122 Dr Bird Statement of Medical Diagnosis

DHC.0002.0001.0125 Residential Medication Management Review

DHC.0002.0001.0159 Email from L Fowler to April Creed

DHC.0002.0001.0162 Letter from plastic surgeon to Dapto Healthcare

144

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document Number Number

Exhibit

DHC.0002.0001.0173 Letter from Dapto Healthcare to IRT

DHC.0002.0001.0177 Health Summary Sheet

DHC.0002.0001.0181 Health Summary Sheet

DHC.0002.0001.0188 Pathology report

DHC.0002.0001.0190 Pathology report

DHC.0002.0001.0192 Blood test

DHC.0002.0001.0194 Blood test

DHC.0002.0001.0195 Blood count

DHC.0002.0001.0196 Specimen test

DHC.0002.0001.0198 Serum

RCD.9999.0099.0002 Letter from IRT to Dapto Healthcare

RCD.9999.0105.0001 Prabhu et al, Passive movements for the treatment and prevention of contractures, Cochrane Database of Systematic Reviews 2013, Issue 12.

RCD.9999.0105.0032 Extract from Potter and Perry’s Fundamentals of Nursing 2017 (5th edition).

SUB.0001.0069.0029 IRT Group provider response

SUB.0001.0069.1455 IRT William Beach Gardens provider response

RCD.9999.0106.0001 National Aged Care Mandatory Quality Indicator Program Manual 1.0

DHC.0002.0001.0169 Mrs Shirley (Shirley) Fowler

RCD.9999.0108.0001 “Chronology”

RCD.9999.0104.0001 Letter to Royal Commission from Alex Rickarby 05.07.19 (NTG-0259 #1)

RCD.9999.0104.0009 Letter to Royal Commission from Alex Rickarby 05.07.19 (NTG-0259 #2)

6-9 WIT.0103.0001.0001 Statement of Lyndall Helen Fowler

6-10 WIT.0103.0002.0001 Statement of Lyndall Helen Fowler to Royal Commission Into Safety and Quality of Aged Care

6-11 WIT.0259.0001.0001 Amended Statement of Kristy Lee Taylor

6-12 WIT.0259.0002.0001 Statement of Sophoronia Briguglio

DHC.0002.0001.0174 Letter from Dapto Healthcare to ACAT

DHC.0002.0001.0179 Health Summary Sheet

DHC.0002.0001.0183 Letter from Dapto Healthcare to Palliative Care

DHC.0002.0001.0189 Blood test

DHC.0002.0001.0191 Blood test

DHC.0002.0001.0193 Histopathology Report

DHC.0002.0001.0197 Liver function test

DHC.0002.0001.0199 Serum

145

Appendix 4 Exhibits

Day 33 – 10 July 2019

Exhibit Number Document Number

Exhibit

6-13

Assisi Tender Bundle

ACL.501.0001.9004 Standard 2.5 (02) Diabetes Management

ACL.501.0002.2747 Staff Night Routines Updated 8/9/2016

ACL.501.0002.2611 Staff Night Routines Updated 29/9/2016

ACL.501.0002.2631 St Anthony 7 - 11am shift.docx

ACL.501.0001.9247 Standard 2.7 Medication Management

ACL.001.0015.0009 Assisi Centre Aged Care: Standard 2.11 Wound Management

ACL.500.0001.9530 Standard 2.11 - Wound Management & Standard 2.8 - Pain Management

ACL.500.0001.2526 Queensland FRAT - Santoro, Annuziata

ACL.500.0001.2780 Norton Risk Assessment Scale - Santoro, Annuziata

ACL.501.0001.3618 Email to Unit Managers titled ‘Mrs. Santoro’

ACL.500.0001.2512 Physiotherapy Assessment - Santoro, Annuziata

ACL.500.0001.2454 Nutrition & Hydration Assessment - Santoro, Annunziata

ACL.500.0001.2415 Mobility Transfers & Dexterity Assessment - Santoro, Annunziata

ACL.500.0001.2525 Psychogeriatric Assessment Scale (PAS) - Santoro, Annuziata

ACL.500.0001.2585 Pain Care Plan - Santoro, Annuziata

ACL.500.0001.2606 Risk Care Plan - Santoro, Annuziata

ACL.500.0001.2742 Cornell Depression Scale - Santoro, Annuziata

ACL.501.0002.3209 Medication Care Plan - Santoro, Annuziata

ACL.501.0001.3601 Email from A Ng titled ‘FW: Annunziata Santoro’

ACL.001.0004.0038 Resident Medication Chart - Santoro Annunziata

ACL.501.0002.5390 Staff Survey Report 2017

ACL.501.0001.3594 Email chain between A Ng and Unit managers, Catering titled ‘FW: Annunziata Santoro’ (16/7/2017 - 25/07/2017)

ACL.001.0001.0092 Leisure Lifestyle & Wellbeing Program Form - Santoro, Annunziata

ACL.501.0001.2240 Email from A Ng titled ‘Mrs Santoro’

ACL.501.0001.3583 Email titled ‘FW: Re Mrs Santoro’

ACL.500.0002.0238 Standard 2.11 - SKIN CARE

ACL.501.0001.8784 Standard 2.14 (01) Mobility,dexterity and Rehabilitation

ACL.500.0001.8848 Permanent Resident Agreement, Assisi Centre Aged Care - Santoro, Annunziata

146

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document Number Number

Exhibit

CTH.4003.9000.0118 Roster St Anthony (26/2/18-29/4/18)

ACL.500.0002.0244 Standard 2.4 (1) - CLINICAL CARE - General

ACL.001.0007.0352 Progress Notes for Santoro, Annunziata ACL.501.0001.1442 Email chain between A Ng and A Yao titled ‘Re: Ana Yao Fwd: Mrs Santoro’ (12/04/2018 - 9/04/2018)

ACL.500.0001.0106 Progress notes - Santoro, Annunziata (5 April - 14 April 2018) ACL.501.0001.1438 Email chain between A Ng and A Yao titled ‘Re: Mrs Santoro’ (16/04/2018)

ACL.501.0001.1873 Email between A Yao and A Ng titled ‘FW: Mrs Santoro’

ACL.001.0007.0353 Progress Notes for Santoro, Annunziata

ACL.501.0001.2158 Email titled ‘FW: Special nurse for Mrs Santoro - room 44’

ACL.501.0001.2161 Email from A Yao titled ‘Annunciata Santoro’

ACL.501.0001.1429 Email chain between A Yao and Pharmacy titled ‘RE: Annunciata Santoro’

ACL.501.0001.3548 Email from A Yao titled ‘Annunciata Santoro’

ACL.501.0001.1404 Email chain titled ‘RE: Special Agency for Mrs Santoro’ (18/04/2018 - 19/04/2018)

ACL.001.0007.0367 Progress Notes for Santoro, Annunziata

ACL.501.0001.2107 Email chain between A Yao and A Ng titled ‘FW: Mrs Santoro’ (16/04/2018 - 14/05/2018)

ACL.501.0001.3545 Email chain to Assisi Recriutment titled ‘Regarding private carer for Mrs. Santoro’

ACL.501.0001.3546 Email to Assisi RNs titled ‘Floor height beds’

CTH.4003.9000.0088 Email from A Ng to Aged Care Complaints Vic titled ‘FW: Attention Lucy [SEC=UNCLASSIFIED]’

ACL.001.0001.0035 Mobility Transfers & Dexterity Assessment - Santoro, Annunziata

ACL.001.0001.0045 Medication Assessment - Santoro, Annunziata

ACL.001.0001.0047 Oral & Dental Assessment - Santoro, Annunziata

ACL.001.0001.0052 Personal Hygiene Assessment - Santoro, Annunziata

ACL.001.0001.0056 Norton Risk Assessment Scale - Santoro, Annunziata

ACL.001.0001.0058 Queensland FRAT - Santoro, Annunziata

ACL.001.0007.0206 Pain Care Plan - Santoro, Annunziata

ACL.500.0001.2409 Medication Assessment - Santoro, Annunziata

ACL.501.0001.1379 Email from ACCC titled ‘S18/009440 [SEC=UNCLASSIFIED]’

147

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

ACL.501.0001.1382 Email from A Yao to Assisi RNs & unit managers titled ‘wound chart’

ACL.501.0002.3161 Nutrition & Hydration Assessment - Santoro, Annuziata ACL.500.0001.0113 Repositioning chart - Santoro, Annunziata (Date range: 1 Mar 2018 - 30 April 2018)

ACL.501.0001.1370 Email between chain A Ng and A Yao titled ‘RE: Mrs Santoro’ (29/4/2018 - 30/04/2018)

ACL.501.0001.3540 Email chain titled ‘RE:Mrs Santoro’ (29/4/2018 - 30/4/2018)

ACL.001.0001.0039 Continence & Toileting Assessment - Santoro, Annunziata

ACL.001.0001.0042 Communication & Sensory Assessment - Santoro, Annunziata

ACL.001.0001.0099 Email chain between Anna Ng and Ana Yao from 29 April 2018 - 1 May 2018 titled ‘Mrs Santoro’

ACL.501.0001.1360 Email to A Yao titled ‘Mrs. Santoro’s bed height’

ACL.501.0001.1355 Email chain between A Ng and A Yao titled ‘RE: Mrs Santoro’ (22/04/2018 - 2/05/18)

CTH.4003.9000.0111 Assisi Response to concerns received by the Complaints Commissioner regarding Mrs Nancy Santoro

ACL.501.0001.1335 Email chain between A Ng and A Yao titled ‘RE: Mrs Santoro’ (29/04/2018 - 4/05/18)

ACL.001.0001.0094 Activity Attendee - Santoro, Annunziata

ACL.501.0001.1314 Email to A Yao titled ‘Annunziata Santoro’

ACL.501.0001.1300 Email to A Yao titled ‘Regarding Santoro’

ACL.001.0007.0396 Progress Notes for Santoro, Annunziata - Clinical Care Review (14 Dec 2017 - 13 May 2018)

ACL.001.0007.0118 Email chain between Anna Ng and Ana Yao titled ‘Mrs Santoro’ (13 & 14 May 2018)

CTH.4003.9000.0116 St Anthony - Roster (11/06/2018 - 24/06/2018)

CTH.4003.9000.0129 Nurisng roster (11/06/2018 - 24/06/2018)

ACL.500.0001.9230 Roster Report by Role Date range: 11 Jun - 24 Jun 2018)

ACL.501.0001.1259 Email titled ‘RE: About Mrs Santoro’

ACL.501.0001.1752 Email chain between A Yao and A Ng titled ‘FW: Mrs Santoro’

ACL.501.0001.1220 Email chain btween A Ng and A Yao titled ‘RE: Mrs Santoro’

ACL.501.0001.3504 Email between A Ng and A Yao titled ‘RE: Mrs Santoro’

ACL.001.0001.0021 Progress Notes for Santoro, Annunziata

ACL.500.0001.2339 Medication Assessment - Santoro, Annunziata

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Exhibit Document

Exhibit

Number Number

ACL.500.0001.2432 Mobility Transfers & Dexterity Assessment - Santoro, Annunziata

ACL.501.0001.1188 Email from A Yao to Resident Movement titled ‘Annunciata Santoro’

ACL.501.0001.3733 Abbey Pain Scale & Documentation - Santoro, Annuziata (Various dates)

ACL.501.0001.3492 Email chain between A Ng and A Yao titled ‘RE: Mrs Santoro’ (14/07/2018 - 19/7/2018)

ACL.501.0001.1159 Email chain between A Yao and Dr Tay titled ‘RE: Annunciata Santoro’

ACL.501.0001.1060 Email chain between internal Assisi staff titled ‘RE: Annunciata Santoro’

ACL.501.0001.2568 Email from Assisi Recruitment to Assisi Accounts titled ‘FW: Re: St Anthony timesheets’

ACL.501.0001.1005 Email chain between A Ng and A Yao titled ‘RE: Mrs Santoro’

ACL.001.0001.0110 Progress Notes Detailed - Santoro, Annunziata

ACL.001.0001.0111 Progress Notes Detailed - Santoro, Annunziata

ACL.501.0001.0994 Email from A Yao to Dr Tay titled ‘Annunciata Santoro’

ACL.501.0001.0982 Email chain between A Yao and A Ng, F Santoro, T Santoro titled ‘RE: Annunciata Santoro’

ACL.501.0001.0975 Email chain from A Yao titled ‘RE: A. Santoro’

ACL.501.0001.0973 Email from S Manuel to Dr Tay titled ‘follow UP Mrs Santoro’

ACL.501.0001.5027 Email between Assisi and Dr Tay titled ‘RE: follow UP Mrs Santoro’ (5/8/2018 - 6/08/2018)

ACL.001.0001.0128 Progress Notes Detailed - Santoro, Annunziata (6 Aug 2018 - 7 Aug 2018)

ACL.501.0001.0964 Email from A Yao titled ‘RE: Mrs Santoro’

ACL.501.0001.0956 Email from A Yao to Dr Tay titled ‘Annunciata Santoro’

ACL.501.0001.0940 Email Frank Santoro titled ‘Nancy Santoro’

ACL.001.0001.0140 Progress Notes Detailed - Santoro, Annunziata (18 July 2018 & 11 Aug 2018) ACL.001.0001.0141 Progress Notes Detailed - Santoro, Annunziata (26 July, 2 Aug & 12 Aug 2018)

ACL.001.0007.0026 Progress Notes for Santoro, Annunziata ACL.501.0001.0927 Email titled ‘Possible extra 1 hr Padre Pio 2-3PM and St anthony’

ACL.001.0001.0024 Progress Notes for Santoro, Annunziata

ACL.001.0001.0025 Progress Notes for Santoro, Annunziata

149

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

ACL.501.0001.0923 Email A Ng titled ‘RE: Mrs Santoro’

ACL.501.0001.0906 Email from J Jacob to Assisi Staff titled ‘re Mrs Santoro’ (transfer to St Francis)

ACL.501.0001.0908 Email chain between J Jacob and E Tay titled ‘RE: re Mrs Santoro’

ACL.501.0001.0845 Email from A Yao to A Yao containing photograph of heel wound

ACL.001.0001.0199 Progress Notes Detailed - Santoro, Annunziata

ACL.001.0001.0262 Progress Notes Detailed - Santoro, Annunziata (18 Sept, 3 Oct, 12 Oct 2018) ACL.501.0001.3328 Email from J Jacob to Assis RNs titled ‘re Mrs santoro’

ACL.501.0001.0873 Email chain with J Jacob titeld ‘RE: A. Santoro’

ACL.001.0001.0223 Progress Notes Detailed - Santoro, Annunziata

ACL.001.0001.0224 Progress Notes Detailed - Santoro, Annunziata ACL.001.0001.0233 Progress Notes Detailed - Santoro, Annunziata

ACL.001.0001.0235 Progress Notes Detailed - Santoro, Annunziata (17, 18 Sept & 3 Oct 2018) ACL.001.0001.0236 Progress Notes Detailed - Santoro, Annunziata (25 Sept & 3 Oct 2018)

ACL.001.0007.0215 Progress Notes for Santoro, Annunziata ACL.001.0008.0005 Adverse Event Detailed - Santoro, Annunziata (12 Nov 2017 - 4 Oct 2018)

ACL.500.0001.1753 Adverse Events Review Details (Date range: 1 Jun 2017 - 8 Nov 2018) ACL.001.0001.0239 Progress Notes Detailed - Santoro, Annunziata

ACL.500.0001.0312 Behaviours Chart - Santoro, Annunziata (Date range: 1 Jun 2018 - 8 Nov 2018) ACL.501.0001.3274 Email from A Ng and subsequeent email chain with J Jacob titled ‘RE: ‘

ACL.501.0001.3280 Email with J Jacob titled ‘RE: re Mrs Santoro’

ACL.001.0001.0241 Progress Notes Detailed - Santoro, Annunziata

ACL.001.0001.0243 Progress Notes Detailed - Santoro, Annunziata (2 & 9 Oct 2018) ACL.500.0002.0088 Photo: wound 1 heel

ACL.501.0001.2574 Email chain between A Ng, J Jacob titled ‘FW: Mrs Santoro’ (4/10/2018 - 30/04/2019)

ACL.001.0001.0245 Progress Notes Detailed - Santoro, Annunziata (9 & 10 Oct 2018)

ACL.501.0002.3293 Record of Family Meeting - 14 September 2018

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Exhibit Number Document Number

Exhibit

ACL.001.0001.0263 Progress Notes Detailed - Santoro, Annunziata (10 Oct & 13 Oct 2018)

ACL.001.0001.0246 Progress Notes Detailed - Santoro, Annunziata

ACL.001.0002.0018 Chronic Wound - Right Heel - Assessment - Santoro, Annunziata

ACL.500.0001.2297 Chronic Wound (right heel) Care Plan - Santoro, Annunziata

ACL.001.0001.0254 Progress Notes Detailed - Santoro, Annunziata

ACL.500.0002.0087 Photo: maggots found

ACL.500.0002.0089 Photo: wound 2 lower leg

ACL.500.0002.0090 Photo: wound 3 rt big toe

ACL.500.0002.0091 Photo: wound 4 rt 4th toe

ACL.001.0001.0260 Progress Notes Detailed - Santoro, Annunziata

ACL.001.0002.0012 Personal Hygiene Assessment - Santoro, Annunziata

ACL.001.0006.0084 Wound Audit

ACL.001.0007.0214 Progress Notes for Santoro, Annunziata: Austin Residential Outreach Team

ACL.500.0001.9059 Assisi Review of Event - Pressure Wound

ACL.501.0001.0861 Transfer Form - Santoro, Annunziata

ACL.500.0001.8455 Weights List - Santoro, Annuziata (Date range: 1 Jun 2016 - 8 Nov 2018) ACL.501.0001.0855 Email chain between Dr Eric Tay and Assisi titled ‘RE: Mrs Santoro’

CTH.4003.9000.0387 Assisi Wound Audit Report - Santoro, Annuziata CTH.4003.9000.0323 Email from Aged Care Complaints Vic titled ‘FW: Case S19/004796 [SEC=UNCLASSIFIED]’

ACL.500.0001.0437 Pain Care Plan - Santoro, Annunziata

ACL.500.0001.2636 Chronic Wound (Right Heel) Assessment - Santoro, Annuziata

ACL.501.0001.1524 Email chain between J Jacob and Dr Tay titled ‘FW: Mrs Santoro’ (16/10/2018 - 14/05/2018)

ACL.501.0001.3169 Email from J Jacob to E Tay tiled ‘re Mrs Santoro’

ACL.501.0001.3173 Email chain between J Jacob and Dr Tay titled ‘RE: Mrs Santoro’ (16/10/2018 - 17/10/2018)

ACL.501.0001.5278 Email chain between J Jacob and Dr Tay titled ‘FW: Mrs Santoro’ (16/10/2018 - 14/05/2018)

CTH.4003.9000.0316 Email from Aged Care Complaints Vic titled ‘FW: New Submission from aged Care Complaints Scheme: Lodge a complaint online 2016 [DLM=Sensitive:Personal]’

151

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

CTH.4003.9000.0327 Wound Details (Date range: 18 July 2018 - 17 Oct 2018) ACL.500.0001.6320 Pain Monitoring Details - Santoro, Annuziata (Date range: 1 Jun 2016 - 8 Nov 2018)

ACL.001.0002.0244 Resident Medication Chart

ACL.001.0002.0246 Resident Medication Chart - Santoro Annunziata

ACL.001.0007.0481 Assisi written response with regard to concerns raised re. Santoro, Annuziata

ACL.500.0001.2266 Risk Care Plan - Santoro, Annunziata

ACL.500.0001.2333 Chronic Wound (Right Heel) Care Plan - Santoro, Annunziata

ACL.500.0001.2737 Physiotherapy Assessment - Santoro, Annuziata

ACL.500.0001.2807 Penisular Health FRAT - Santoro, Annuziata

ACL.500.0001.9959 Assisi Wound Audit Report - Santoro, Annuziata

ACL.501.0001.0609 Progress notes - Santoro, Annuziata - Doctors reviews (Date range: 1 Jun to 19 Oct 2018) ACL.501.0001.3056 Abbey Pain Scale - Santoro, Annunziata (Bundle of 5, multiple dates)

CTH.4003.9000.0350 Multiple Chronic wound (right heel) Assessments Santoro, Annuziata. Resident medication chart

CTH.4003.9000.0391 Weight Chart 2018 & Pain Details (Oct 2018)

CTH.4003.9000.0400 Progress notes - Summary and system entries (13/05/2018 - 13/09/2018)

CTH.4003.9000.0418 Progress notes (14 Oct - 19 Oct 2018)

CTH.4003.9000.0445 Progress notes (Sept 2018 - Oct 2018)

ACL.001.0002.0026 Progress Notes - Santoro Annunziata, Date range: 1 Jul 2018 - 31 Jan 2019

ACL.500.0001.1493 Wound Monitoring (Appearance Details) - Santoro, Annunziata (Date range: 1 Jun 2018 - 8 Nov 2018)

ACL.500.0001.6228 Client communications - Santoro, Annuziata (Date range: 1st June 2016 to 8th Nov 2018) ACL.500.0001.8543 Wound Monitoring (Treatment Details) - Santoro, Annuziata (Date range: 1 Jun 2016 - 8 Nov 2018)

ACL.501.0001.3815 Communication, Organiser - Mrs Santoro (Date range May 2018 - Oct 2018) ACL.501.0001.4310 Medication charts & Patient History - Annuziata Santoro (1/7/18 - 1/10/18)

CTH.4003.9000.0470 Assisi Written Response with regard to the following concerns.docx

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Exhibit Number Document Number

Exhibit

CTH.4003.9000.0544 Regular medication signing charts (July - October 2018)

CTH.4003.9000.0485 Record of notes taken by A Ng (Sept 2018 - Oct 2018)

CTH.4003.9000.1107 Email titled ‘Active wound review’

CTH.4003.9000.0477 Email with A Ng forwarded to Aged Care Complaints Vic titled ‘FW: Mrs Santoro S19- 004796 [Sec=Unclassified]’

CTH.4003.9000.0482 Email chain between A Ng and J Jacob forward to Aged Care Complaints Vic titled ‘FW: re Mrs Santoro’s general update s 19-004796 Robert Rogers [Sec=Unclassified’]

ACL.500.0001.9285 Email titled ‘re wound one to one session with ‘ & CQI Plan Items

CTH.4003.9000.0778 Email with CQI Plan Items Doc attached

CTH.4003.1000.0903 Letter from Delegate of the Aged Care Complaints Commissioner to CEO, AACQA titled ‘S19/004796 Type 2 Referral - Significant issue/concern - Assisi Centre Aged Care - RACS ID 3364’

CTH.4003.1000.1499 AACQA Assessment Contact Report Assisi Centre Aged Care

CTH.4003.9000.1001 Email from ACQSC titled ‘Case ID S19/004796 Assisi Centre - Mrs Santoro [Sec=Unclassified]’

ACL.501.0001.0131 Progress notes - Santoro, Annuziata (July 2018 to October 2018)

CTH.4003.9000.1003 Email from ACQSC titled ‘Case ID S19/004796 Assisi [SEC=UNCLASSIFIED]’ CTH.4003.9000.1136 Emails between ACQSC and Dr Tay titled ‘RE: Case ID S19/004796 Assisi - Mrs A Santoro [SEC=UNCLASSIFIED’]

CTH.4003.9000.1152 Email from Aged Care Complaints Clinical Advice titled ‘RE: CAse ID S19/004796 Assisi Centre (Maggots) [DLM=Sensitive:Personal]’ CTH.4003.9000.1156 Email chain between Aged Care Quality Vic and A

Ng titled ‘Case ID S19/004796 Assisi - Mrs Santoro [SEC=UNCLASSIFIED]’ (16/2/2019 - 18/2/2918)

CTH.4003.9000.1283 Forwarded email from A Ng to Aged Care Quality Vic titled ‘FW: S19/004796 [Sec=Unofficial]’

ACL.501.0001.5129 Board Minutes 25 March 2019.pdf

ACL.501.0003.0191 Minutes of the Special Board Meeting 1 April 2019

ACL.001.0007.0197 Information Required by Complaints Commission

ACL.500.0001.0299 Assisi Centre Aged Care: Standard 2.10 Nutrition and Hydration

ACL.500.0002.0271 Standard 2.8(1) - PAIN MANAGEMENT

CTH.4003.9000.0475 Email chain between A Ng and Dr Tay forwarded to Aged Care Complaints Vict titled ‘FW: re Mrs Santoro’s medications review. S19-004796 [Sec=Unclassified]’

153

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

ACL.501.0002.3014 Care Directives - Chronic Wounds (1/05/2016 - 10/05/2019) ACL.501.0002.5540 Historical Drug Usage and PRN Administration Record - Mrs A Santoro

ACL.501.0004.0003 Letter from ACQSC, Case ID: S19/004796

ACL.501.0001.0326 Assisi Summary - Mrs Santoro

ACL.501.0002.2757 Night Shift Floater duty list

AMN.0001.0001.0001 Photo

AMN.0001.0001.0002 All about me AMN.0001.0001.0003 Assisi Centre Inc Residents, Families and Friends Meeting Minutes

AMN.0002.0001.0001 Email correspondence between Anna Ng and Assisi Centre Aged Care re complaint AMN.0002.0001.0007 Letter from Aged Care Quality and Safety Commission to Anna Ng attaching feedback and outcomes

AMN.0003.0001.0001 Photo

AMN.0004.0001.0001 Email from Andrew Place Clinic to Anna Ng re medication

SUB.0001.0026.0424 Letter from Assisi Aged Care to Royal Commission into Aged Care Quality and Safety re provider response SUB.0001.0026.0387 Assisi Aged Care Submission to the Royal Commission into Aged Care Quality and Safety

ACL.500.0001.3586_E Progress Notes from 12/11/2017 - 13/11/2017

ACL.001.0004.0364 Austin Health Discharge Summary

ACL.001.0004.0373 Austin Health Patient Summary Report

ACL.500.0001.3592_E Progress Notes from 21/11/2017 - 22/11/2017

ACL.001.0004.0078 Austin Health Advance Care Plan

ACL.500.0001.3602_E Progress Notes from 12/12/2017 - 14/12/2017

ACL.001.0004.0264 Austin Health Discharge Summary

ACL.001.0004.0279 Austin Health Patient Summary Report

ACL.001.0004.0354 Hospital Discharge Summary

ACL.500.0001.3660_E Progress Notes for 17/04/2018

ACL.500.0001.3683_E Progress Notes for 26/04/2018

ACL.500.0001.3755_E Progress Notes for 14/06/2018

ACL.001.0004.0252 Austin Health Patient Summary Report

CTH.4003.9000.0267 Finalisation letter from Aged Care Quality and Safety Commission to Ms Ng

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Exhibit Number Document Number

Exhibit

ACL.001.0004.0259 Austin Health Assessment Form

ACL.500.0001.3780_E Progress Notes from 12/07/2018 - 17/07/2018

ACL.001.0004.0218 Austin Health Encounter Summary

ACL.001.0004.0213 Austin Health Emergency Discharge Documentation

ACL.001.0004.0216 Austin Health Patient Summary Report

ACL.500.0001.3827_E Progress Notes for 08/08/2018

ACL.500.0001.3848_E Progress Notes from 19/08/2018 to 20/08/2018

ACL.500.0001.3898_E Progress Notes from 16/09/2018 to 17/09/2018

ACL.500.0001.3901_E Progress Notes for 18/09/2018

ACL.500.0001.3937_E Progress Notes from 03/10/2018 to 04/10/2018

ACL.500.0001.3947_E Progress Notes from 09/10/2018 to 12/10/2018

RCD.0003.0258.0001 Notice to Give to Assisi Centre Limited (NTG-0258)

DET.0001.0001.0001 Andrew Place Clinic records between 26/04/2018 to 18/10/2018

DET.0001.0002.0001 Bundle of emails from E Tay between 17/04/2018 to 26/10/2018

CTH.4003.1000.0037 Audit Assessment Information - Assisi Centre Aged Care

CTH.4003.1000.0035 Re-Accreditation Decision and STATEMENT of Reasons

CTH.4003.1000.0455 Assessment Contact Advice - Assisi Centre Inc

CTH.4003.1000.0456 Assessment Contact Report - Assisi Centre Inc

CTH.4003.1000.0901 Assessment Contact Advice - Assisi Centre Inc

CTH.4003.1000.0895 Assessment Contact Report - Assisi Centre Inc

CTH.4003.1000.1510 Assessment Contact Advice - Assisi Centre Limited

ACL.501.0001.9399 Std 2.7 (3) Application of Medicated Creams and Lotions.doc

ACL.001.0017.0100 Pain Management Policy

ACL.501.0001.9383 Std 2.7 (1) Medication Management - High Care Facility.doc

ACL.501.0001.9391 Std 2.7 (2) Medication Management - Hostel.doc

ACL.001.0017.0014 Clinical Care - General Policy

ACL.501.0001.9657 Assisi Centre Aged Care Std 2.4 (01) - CLINICAL CARE - General.doc

ACL.001.0017.0053 Other Health and Related Services Policy

RCD.0010.0001.0101 Letter from Royal Commission to Assisi Centre Limited re Darwin Cairns Hearing

DET.0001.0003.0001 Emails between E Tay and A Ng between 01/11/2018 to 15/11/2018

155

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

ACL.001.0017.0155 Therapeutic (Modified) Diet Menus Policy

ACL.001.0017.0168 Assisi Centre Aged Care Std 2.11 Skin Care Policy

ACL.501.0001.9602 Assisi Centre Aged Care Std 2.12 - CONTINENCE MANAGEMENT.doc

ACL.001.0017.0032 Hand Over Policy and Procedure

ACL.001.0017.0029 Adverse Event Management Policy

ACL.501.0001.9667 Assisi Centre Aged Care Std 2.5 (01) - SPECIALISED NURSING CARE PROCEDURE.doc

ACL.501.0002.0055 Assisi Centre Aged Care Std 3.9.(01) Choice and decision making.doc

ACL.001.0017.0114 Assisi Centre Aged Care Std 2.9 Palliative Care Policy

ACL.001.0005.0102 Staff Orientation and Induction Program

ACL.001.0017.0035 Management of Acute Clinical Events Policy

ACL.001.0017.0098 Resident Self Administration of Medications Policy

ACL.501.0001.8817 Assisi Centre Aged Care 2.4 (05) Managment of Acute Clinical Events.docx

ACL.501.0002.0027 Assisi Centre Aged Care Std 3.6.(02) Death and Dying with dignity.doc

ACL.501.0002.0029 Assisi Centre Aged Care Std 3.7 (01) Leisure Interests and Activities.doc

ACL.501.0002.0038 Assisi Centre Aged Care Std 3.8 (01) Cultural and Spiritual Life.doc

ACL.501.0002.0057 Assisi Centre Aged Care Std 3.9.(02) Committees residents and friends.doc

ACL.501.0002.0004 Assisi Centre Aged Care Std 3.4 (01) Emotional Support.doc

ACL.501.0001.8726 Assisi Std 2.11 Wound Care.doc

ACL.501.0001.9275 Assisi Centre Aged Care Std 2.8 - Pain Management

ACL.501.0002.4885 Assisi Falls Management Policy

ACL.001.0017.0057 Medication Management Policy

ACL.501.0002.0067 Education & Training from 02/05/2016 to 14/05/2019

ACL.001.0017.0139 Nutrition and Hydration Policy

ACL.001.0003.0175 Application for Respite Care or Permanent Entry to Assisi Centre Aged Care - Santoro Annunziata

ACL.500.0001.4886 Blood Glucose Levels from 24/06/2016 to 15/10/2018

ACL.501.0001.8810 Assisi Centre Aged Care 2.4 (03) Adverse Event Management.doc

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Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Number Document Number

Exhibit

ACL.501.0001.8102 Validation from 24/06/2016 to 30/10/2018

ACL.501.0002.4351 Urinalysis List from 24/06/2016 to 17/10/2018

ACL.501.0002.4766 Bowels Monitoring Chart from 24/06/2016 to 23/10/2018

ACL.501.0002.3615 Client Care Document Care Plan Initial

ACL.500.0002.0100 Annunziata Santoro Comprehensive Assessment

ACL.501.0002.4906 Assisi Wound Management Policy

ACL.001.0007.0031 Pain Care Plan

ACL.501.0001.6118 Staffing Report by Role from 29/05/2017 to 08/10/2017

ACL.001.0004.0400 Long Term Medication Management Chart - Annunziata Santoro as at 13/06/2017

ACL.001.0004.0095 Activity and Interest Checklist

ACL.001.0004.0440 Pathology results

ACL.500.0001.1641 Activity Attendance from 15/06/2017 to 23/10/2018

ACL.500.0001.4272 Weight Monitoring from 15/06/2017 to 16/10/2018

ACL.501.0002.3611 Client Care Document Norton Risk Scale

ACL.501.0002.4864 Initial Assessment

ACL.501.0002.3806 Pain Monitoring Details from 23/06/2017 to 23/10/2018

ACL.501.0002.2846 Behaviours Monitoring from 04/07/2017 to 5/10/2018

ACL.500.0001.2774 Client Care DocumentAssessment Continence & Toileting 12th July 2017.pdf

ACL.001.0016.0056 Abbey Pain Scale

ACL.501.0002.3097 Client Care Document Care Plan Risk

ACL.001.0004.0015 ACFI 5 Continence - Assessment

ACL.501.0001.4600 Email from A Ng re Mrs Santoro

ACL.500.0001.2308 Client Care Document Care Plan Leisure Lifestyle & Wellbeing from 24/08/2017 to 17/01/2018

ACL.500.0001.2399 Client Care Document Assessment leisure Lifestyle & Wellbeing 24th August 2017.pdf

ACL.500.0001.9218 Leisure Lifestyle Program form from 24/08/2017 to 17/01/2018 ACL.500.0001.2388 Client Care Document Assessment Continence & Toileting 6th September 2017.pdf

ACL.500.0001.2596 Client Care Document Care Plan Physiotherapy 22nd June 2017.pdf

ACL.500.0001.2772 Client Care DocumentAssessment Client Profile Form from 22/08/2017 to 21/09/2018

157

Appendix 4 Exhibits

Exhibit Number Document Number

Exhibit

ACL.500.0001.2598 Client Care Document Care Plan Physiotherapy 22nd September 2017.pdf

ACL.500.0001.2905 Infection Monitoring from 27/09/2017 to 03/10/2018

ACL.500.0001.0152 Weight Chart 2018 from 06/10/2017 to 16/09/2018 and Pain Details from 15/10/2018 to 19/10/2018

ACL.502.0001.0346 Roster Report by Role from 09/10/2017 to 06/05/2018

ACL.500.0001.2304 Client Care Document Care Plan Contnence & Toileting.pdf

ACL.001.0008.0030 Adverse Events List from 12/11/2017 to 04/10/2018

ACL.001.0002.0082 Abbey Pain Scale

ACL.501.0002.3283 Client Care Document Risk Scale Norton Risk Assessment Scale

ACL.001.0006.0007 Internal Transfer Checklist

ACL.501.0001.8797 Assisi Centre Aged Care 2.4 (02) Clinical Documentation.doc

ACL.500.0001.2612 Client Care Document Care Plan Risk 5th December 2017.pdf

ACL.500.0001.2302 Client Care Document Care Plan Continence 12th December 2017.pdf

ACL.500.0001.2360 Client Care Document Assessment Continence &Toileting 12th December 2017.pdf

ACL.501.0002.3281 Client Care Document Nutrition & Hydration ACL.500.0001.2355 Client Care Document Advanced Care Plan Authorisation 14th December 2017.pdf

ACL.500.0001.3236 Oxygen Saturation Monitoring from 25/12/2017 to 23/10/2018

ACL.001.0017.0205 Mobility Dexterity and Rehabilitation Policy

ACL.500.0001.2508 Client Care Document Assessment Physiotherapy 9th January 2018.pdf ACL.500.0001.2791 Client Care Documentcare Plan Physiotherapy 9th January 2018.pdf

ACL.501.0001.4592 Internal email re Assisting Nancy to settle into care

ACL.001.0007.0400 Whereabouts Chart from 08/02/2018 to 01/09/2018

ACL.501.0002.0685 Assisi Centre Aged Care 4.4.(03) Restraint Management.docx

ACL.501.0001.2171 Emailsfrom A Ng re Mrs Santoro

ACL.500.0001.2504 Client Care Document Assessment Physiotherapy 6th April 2018.pdf ACL.501.0002.4369 Wound Monitoring Appearance Details List from 17/04/2018 to 23/10/2018

ACL.500.0001.2755 Client Care Document Risk Scale Queensland FRAT 22nd Nov2017.pdf

158

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Number Document Number

Exhibit

ACL.501.0002.4383 Wound Monitoring Notes List from 17/04/2018 to 23/10/2018

ACL.001.0007.0361 Progress Notes for Santoro Annunziata

ACL.500.0001.2488 Client Care Document Assessment Physiotherapy 18th April 2018.pdf

ACL.001.0007.0368 Progress Notes for Santoro Annunziata

ACL.001.0007.0372 Progress Notes for Santoro Annunziata

ACL.001.0007.0374 Progress Notes for Santoro Annunziata

ACL.001.0001.0057 Abbey Pain Scale

ACL.001.0001.0061 Risk Care Plan

ACL.001.0002.0083 Abbey Pain Scale

ACL.501.0002.3207 Client Care Document Care Plan Continence & Toileting

ACL.501.0002.3249 Client Care Document Norton Risk Asessment Scale

ACL.502.0001.0455 Roster Report by Role from 07/05/2018 to 31/10/2018

ACL.001.0007.0169 Dietary Supplement Record Chart

ACL.001.0015.0209 Email from Physiotherapist to Assisi re Manual Handling Training Content ACL.500.0001.0397 Food and Fluid Monitoring Details from 01/06/2018 to 24/06/2018

ACL.500.0001.9093 Doctors reviews from 01/06/2018 to 19/10/2018

ACL.501.0001.0072 Doctors reviews from 01/06/2018 to 19/10/2018

ACL.001.0007.0187 Dietary Supplement Record Chart

ACL.501.0002.4409 Nutrition & Hydration Assessment

ACL.001.0007.0188 Dietary Supplement Record Chart

ACL.001.0007.0189 Dietary Supplement Record Chart

ACL.001.0007.0190 Dietary Supplement Record Chart

ACL.001.0007.0191 Dietary Supplement Record Chart

ACL.500.0001.1491 Wound Details from 09/06/2018 to 18/10/2018

ACL.001.0007.0192 Dietary Supplement Record Chart

ACL.001.0007.0193 Dietary Supplement Record Chart

ACL.001.0007.0194 Dietary Supplement Record Chart

ACL.500.0001.2757 Client Care Document Risk Scale Queensland FRAT 27th April 2018.pdf

ACL.500.0001.1599 Wound Monitoring Treatment List from 09/06/2018 to 22/10/2018

Appendix 4 Exhibits

159

Exhibit Document

Exhibit

Number Number

ACL.500.0001.2789 Client Care DocumentCare Plan Physiotherapy 12th June 2018.pdf

ACL.001.0007.0195 Dietary Supplement Record Chart

ACL.500.0001.1079 Infection Monitoring Details from 14/06/2018 to 11/10/2018

ACL.500.0001.2566 Client Care Document care Plan Mobility Transfers & Dexterity 15th June 2018.pdf ACL.501.0002.5039 Assisi Centre Aged Care Training Schedule July - December 2018

ACL.500.0001.0323 Bladder Monitoring from 02/07/2018 to 06/07/2018

ACL.501.0001.1217 Emails between A Ng and A Yao re Audiologist for Mrs Santoro

ACL.500.0001.2600 Client Care Document care Plan Physiotherapy 6th April 2018.pdf ACL.500.0001.2550 Client Care Document Care Plan Continence & Toileting 12th July 2017.pdf

ACL.001.0002.0007 Personal Hygiene Assessment

ACL.001.0002.0084 Abbey Pain Scale

ACL.001.0007.0035 Abbey Pain Scale

ACL.001.0007.0211 Norton Risk Assessment Scale

ACL.500.0001.1069 Client Summary Care Plan

ACL.501.0001.8431 Wound Details from 18/07/2018 to 23/10/2018

ACL.500.0001.2492 Client Care Document Assessment Physiotherapy 19th July 2018 (2).pdf ACL.500.0001.2496 Client Care Document Assessment Physiotherapy 19th July 2018.pdf

ACL.500.0001.9542 Wound charting from 21/07/2018 to 12/09/2018

ACL.001.0007.0395 Whereabouts Chart from 29/08/2018 to 04/09/2018

ACL.001.0001.0181 Progress Notes Detailed - Speech Pathology Assessment Report

ACL.500.0001.9511 Santoro Progress notes from 18/09/2018 to 13/10/2018

ACL.500.0001.2396 Client Care Document Assessment Leisure Lifestyle & Wellbeing 19th September 2018.pdf ACL.501.0001.1561 Emails between A Ng and J Jacob re Dietician review for Mrs Santoro

ACL.001.0016.0117 Wound Monitoring - Treatment Details from 01/10/2018 to 23/10/2018 ACL.500.0001.2516 Client Care Document Assessment Physiotherpay 2nd October 2018.pdf

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Number Document Number

Exhibit

160

ACL.001.0004.0061 Whereabouts Chart from 03/10/2018 to 16/10/2018

ACL.001.0002.0190 Progress Notes from 15/10/2018 to 17/10/2018

ACL.501.0001.1516 Emails J Jacob re Dietician review for Mrs Santoro

ACL.501.0001.1983 Emails J Jacob re Dietician review for Mrs Santoro

ACL.001.0002.0085 Abbey Pain Scale

ACL.001.0002.0239 Pain Care Plan

ACL.001.0016.0063 Risk Care Plan

ACL.500.0001.2809 Client Care Documents Physiotherapy Care Plan 19th October 2019.pdf

ACL.501.0001.6538 Nutrition & Hydration Assessment

ACL.501.0002.4443 Continence & Toileting Care Plan

ACL.501.0002.4467 Risk Care Plan

ACL.001.0004.0080 End of Life Wishes

ACL.501.0002.4894 Assisi Handover Policy and Procedure

ACL.501.0001.0344 Residents families Guide January 2019- highlighted.pdf

ACL.501.0001.8789 Assisi 2.14 (02) Falls Management.doc

ACL.001.0007.0329 Weight Report

ACL.501.0002.5559 Assisi Medication Management Policy

ACL.502.0001.0344 Emails between Assisi and Physiotherapist titled “Re Private Physiotherapy Invoices at Assisi” ACL.001.0004.0091 Assisi Centre Aged Care - Nursing Staff - Permanent Resident Admission Checklist

ACL.001.0004.0097 Leisure & Lifestyle Profile

ACL.501.0001.0474 Daily organizer tasks and daily wound monitoring details.pdf

ACL.501.0001.9366 Assisi Centre Aged Care Std 2.1 to 2.3.doc

ACL.501.0001.6683 Progress Notes from 24/06/2016 to 30/10/2018

ACL.501.0002.3853 Progress Notes from 24/06/2016 to 30/10/2018

ACL.502.0001.1254 Attachment 3 - Email exchanges Complaints Commissioner.pdf

ACL.501.0001.5142 Board Minutes 29 October 2018.pdf

ACL.502.0001.1292 AGM Minutes November 2018.pdf

ACL.500.0001.2804 Client Care DocumentNutrition & Hydration Care Plan 19th October 2018.pdf

ACL.502.0001.1276 Attachment 5 - Complaints Commissioner Notification incorrectly addressed to Peter Staples and Eileen Kielty.pdf

Appendix 4 Exhibits

161

Exhibit Document

Exhibit

Number Number

ACL.502.0001.1242 Attachment 2 - Assessment Contact Report from the Complaints Commissioner.pdf

ACL.502.0001.1262 Attachment 4 - Email Exchanges Complaints Commissioner.pdf

ACL.501.0001.5138 Board Minutes 29 January 2019.pdf

ACL.501.0001.5125 Board Minutes 25 February 2019.pdf

ACL.502.0001.1238 Attachment 1 - Exchange of Don P & CEO Emails.pdf

ACL.501.0001.5129 Board Minutes 25 March 2019.pdf

ACL.502.0001.0642 Attachment 07 - CEO Review Into Complaint 05072013.pdf

ACL.502.0001.0645 Attachment 07.1 - Complaints Flow Chart 2013.pdf

ACL.502.0001.0646 Attachment 07.2 - Complaints Flow Chart 2019.pdf

ACL.502.0001.0647 Attachment 08 - Rationale for RC Submission.pdf

ACL.501.0003.0191 Minutes of the Special Board Meeting of 1 April 2019.pdf

ACL.501.0001.5134 Board Minutes 29 April 2019.pdf

ACL.501.0003.0194 Minutes of the Special Board Meeting of 15 May 2019.pdf

ACL.502.0001.1288 Board Minutes 27 May 2019.pdf

ACL.502.0001.1295 Board Minutes 26 June 2019.pdf

RCD.9999.0101.0001 Linkedin Profile

ACL.001.0007.0488 Email from Aged Care Commplains Commissioner to Assisi

ACL.501.0001.5161 CEO Report for Board Meeting of 29 October 2018

ACL.001.0006.0043 Email from Aged Care Complaints Commissioner to Assisi

ACL.501.0001.4485 Email from Aged Care Quality and Safety Commission to Assisi

ACL.501.0001.5156 CEO Report for Board Meeting of 29 January 2019

ACL.502.0001.1156 Agenda - Board Meeting 29 January 2019

ACL.501.0001.5146 CEO Report for Board Meeting of 25 February 2019

ACL.502.0001.1459 Review into Complaint - Event Fall - 5 July, 2013

ACL.502.0001.1432 Email correspondece from Aged Care Online re complaint

ACL.502.0001.1440 Email from D Smarrelli to Board Members

ACL.502.0001.1303 Report to Chair re AS - Prepared by CEO

ACL.502.0001.0716 Attachment 03 - Meeting Action Sheet 25 March 2019

ACL.001.0006.0035 Letter from Aged Care Complaints Commissioner to Assisi Centre Limited

ACL.501.0001.5121 Appendix 3 to CEO Report for Board Meeting of 25 February 2019 - Chronological Reporting on a Complaint regarding Mrs S

162

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

ACL.502.0001.0735 Attachment 13 - CEO Report 25 March 2019

ACL.502.0001.1040 Attachment 03 - Meeting Action Sheet 29 April 2019

ACL.501.0001.5150 CEO Report for Board Meeting of 29 April 2019

RCD.9999.0110.0001 Chronology - Assisi Case Study

6-15 WIT.0169.0001.0001 Statement of Anamaria Ng 6-16 WIT.0248.0001.0001 Statement of Eric Tiong Yew Tay

Day 34 – 11 July 2019

Exhibit Number Document Number

Exhibit

6-17 WIT.0258.0001.0001 Statement of Paul Stephen Cohen

6-18 WIT.0258.0002.0001 Supplementary Statement of Paul Stephen Cohen

6-20 WIT.0221.0001.0001 Statement of Lisa Maree Backhouse

6-22 WIT.0196.0001.0001 Statement of Johanna Irene Mary Westbrook

6-24 WIT.0273.0001.0001 Amended Statement of Michael John Murray

6-26 WIT.0222.0002.0001 Second Statement of Joan Ostaszkiewic

6-28 WIT.0240.00001.0001 Statement of Catherine Anne Sharp

6-29 WIT.0257.0001.0001 Statement of Sally Jeanne Hopkin

6-30 WIT.0257.0001.0001 Joint Statement of Geoffrey Mendes Sussman and Hayley Maree Ryan on Behalf of Wounds Australia

Day 35 – 12 July 2019

Exhibit Number Document Number

Exhibit

6-31 WIT.0209.0001.0001 Statement of Jo-Ann Mayse Lovegrove

6-32 WIT.0251.0001.0001 Statement of Janet Kathleen Sluggett

6-33 WIT.0198.0001.0001 Statement of Catherine Mary Maloney

6-34 WIT.0255.0001.0001 Statement of Larrakia Nation Aboriginal Corporation

6-14 WIT.0271.0001.0001 Statement of Robert Keith Bird

6-19 WIT0288.0001.0001 Statement of Donato Smarrelli

6-21 WIT.0197.0001.0001 Statement of Associate Professor Peter Neil Gonski

6-23 WIT.0196.0002.0001 Second Statement of Johanna Irene Mary Westbrook

6-25 WIT.0222.0001.0001 First Statement of Joan Ostaszkiewic

6-27 WIT.0222.0003.0001 Corrigendum Prepared by Joan Ostaszkiewicz

163

Appendix 4 Exhibits

Day 36 – 15 July 2019

Exhibit Document

Exhibit

Number Number

6-35 Avondrust Tender Bundle

WIT.0220.0001.0001 Statement Of Johanna Aalberts Henderson

WIT.0260.0001.0001 Statement Of Robert Van Duuren

RCD.9999.0121.0001 Consolidated Annexure To Statement Of Robert Van Duuren

WIT.0260.0002.0001 Statement Of Petronella Neeleman

WIT.0278.0001.0001 Statement Of Jan Rice

WIT.0293.0001.0001 Supplementary Statement Of Jan Rice

JAA.0001.0001.0041 Photograph Of Mrs Aalberts’ Room

JAA.0001.0001.0042 Photograph Of Mrs Aalberts

JAA.0001.0001.0043 Photograph Of Mrs Aalberts (First Day)

JAA.0001.0001.0048 Photograph Of Mrs Aalberts’ Right Foot

JAA.0001.0001.0049 Photograph Of Mrs Aalberts’ Arm (Plastered)

JAA.0001.0001.0052 Photograph Of Debrided Wound

JAA.0001.0001.0054 Photograph Of Ear

JAA.0001.0001.0055 Photograph Of Haematoma On Shin

JAA.0001.0001.0058 Photograph Of Mrs Aalberts’ Left Knee

JAA.0001.0001.0059 Photograph Of Mrs Aalberts’ Left Knee

JAA.0001.0003.0002 Photograph Beth Aalberts (Age 12)

JAA.0001.0003.0005 Photograph Beth Aalberts (Honeymoon)

JAA.0001.0003.0008 Photograph Beth Aalberts (Age 17)

MIC.0001.0001.0304 Adverse Drug Reaction - Bertha Aalberts Beth - Mrn Mq00110542 - Adm No Aq02330280

MIC.0001.0001.0313 Dietary Card Master - Beth Aalberts - Room No 17

MIC.5000.0001.2600 Avondrust Qualification Register.Docx

MIC.5000.0001.3051 Micare Interaction Rules.Pdf

CTH.4007.9000.0398 Aacqa Human Resource Management

CTH.4007.9000.0065 Avondrust Care Plan For Bertha

MIC.5000.0001.3239 Staff Training Register.Xls

CTH.4007.1000.1386 Aacqa Re-Accreditation Audit Report - Avondrust

MIC.5000.0001.2146 Consumer Experience Report

MIC.5000.0001.2147 Consumer Experience Report

JAA.0001.0001.0025 Letter To Frederick Aalberts Attaching Pharmacy Bill

MIC.5000.0001.3376 Staffing Roster - Ppe 13052018.Pdf

MIC.0001.0001.0186 Lifestyle Personality Profile

MIC.0001.0001.0386 Aged Care Funding Instrument - Application For Classification - Effective From 1 January 2017 - Section 1 Particulars Of Person Being Appraised - Bertha Aalberts

MIC.0001.0001.0024 Application For Residential Aged Care - Application For Avondrust Lodge Carrum Downs - Bertha Aalberts

164

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

MIC.5000.0001.3167 Care Plan.Pdf

MIC.0001.0001.0462 Mini Care Plan - Bertha Aalberts

MIC.0001.0001.0181 Observation Chart - Bertha Aalberts - Room 17

CTH.4007.9000.0251 Incident Forms

MIC.0001.0001.0124 Incident Form - Resident - Bertha Aalberts (17) - Date Of Occurrence Sat 26 May 2018 8:10 Pm

MIC.0001.0001.0439 Checklist Must Be Completed - Bertha Aalberts Rm 17

MIC.0001.0001.0440 Acfi 6 Cognitive Skills - Assessment - Pas - Cis - Bertha Aalberts - Facility Id 3167

MIC.5000.0001.2149 0518 Micare Ltd Board Papers.Pdf

CTH.1013.1004.0199 Audit Report: Micare Avondrust Lodge

CTH.4007.1000.1379 Aacqa Re-Accreditation Decision - Avondrust

CTH.4007.2000.0186 Aacqa Published Decision - Avondrust

MIC.0001.0001.0127 Incident Form - Medication - Bertha Aalberts (17) - Date Of Occurrence Fri 08 Jun 2018 8:00 Pm

MIC.0001.0001.0130 Incident Form - Resident - Bertha Aalberts (17) - Date Of Occurrence Fri 08 Jun 2018 9.00 Pm

MIC.0001.0001.0182 Neurological (Glasgow Coma Scale=Gcs) & Vital Signs Observations - Bertha Aalberts

MIC.5000.0001.3374 Ppe 10062018.Pdf

MIC.5000.0001.3371 Staffing Roster - Ppe 24062018.Pdf

MIC.0001.0001.0177 Form B - Initial Care Plan - Bertha Aalberts

MIC.0001.0001.0139 Incident Form - Medication - Bertha Aalberts (17) - Date Of Occurrence Tue 03 Jul 2018 10:53Am

MIC.0001.0001.0142 Incident Form - Resident - Bertha Aalberts (17) - Date Of Occurrence Tue 03 Jul 2018 7:52 Pm

MIC.0001.0001.0267 Mrs Bertha Aalberts - Dob 13/11/1930 - 21/10 Warrandyte Road Langwarrin 3910 - X-Ray Right Wrist

MIC.0001.0001.0293 Pathology Report - Serum C-Reactive Protein (Crp) - Bertha Aalberts (Beth) - Lab No 18- 37108764

MIC.0001.0001.0312 Elder Dietary Requirements - Bertha Aalberts (Berth(

JAA.0001.0002.0098 Peninsula Private Hospital Notes

MIC.0001.0001.0161 Clinical Variance Record - Berth Aalberts - Room No 17

MIC.0001.0001.0269 Mrs Bertha Aalberts - Dob 13/11/1930 - 21/10 Warrandyte Road Langwarrin 3910 - X-Ray Chest

MIC.0001.0001.0300 Adverse Drug Reaction - Bertha Aalberts Beth - Mrn Mq00110542 - Acc # Aq02330199 - Medication Chart No 1 Of 2 - Authority Prescription No 12196934

MIC.0001.0001.0191 Review And Evaluation Form - Elder Of The Day - Bertha Aalberts - June 2018

MIC.0001.0001.0268 Mrs Bertha Aalberts - Dob 13/11/1930 - 21/10 Warrandyte Road Langwarrin 3910 - Ct Brain

165

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

MIC.0001.0001.0297 Falls Risk Screening Tool - Bertha Aalberts Beth - Mrn Mq00110542 - Adm No Aq02330280

MIC.5000.0001.3368 Staffing Roster - Ppe 08072018.Pdf

MIC.0001.0001.0193 Care Plan - Bertha Aalberts (17)

MIC.0001.0001.0033 Note From Johanna Aalberts-Henderson

MIC.0001.0001.0054 Letter From Dr Bhalla To Dr Nar Re Bertha Aalberts

MIC.0001.0001.0285 Total Care Progress Notes - Mrs Bertha Aalberts - Mrn Mq00110542

MIC.0001.0001.0286 Patient Transfer Form - Non-Time Critical Patients - Transfer Destination Nursing Home - Av - Bertha Aalberts - Mrn Mq00110542 - Adm No Aq02330280

MIC.0001.0001.0287 Wound Worksheet - Bertha Aalberts Beth - Mrn Mq00110542 - Adm No Aq02330280

MIC.0001.0001.0288 Pressure Injury Prevention And Management Plan - Bertha Aalberts Beth - Mrn Mq00110542 - Adm No Aq02330280

MIC.0001.0001.0421 Physiotherapy Assessment - Bertha Aalberts (17)

MIC.0001.0001.0133 Incident Form - Medication - Bertha Aalberts (17) - Date Of Occurrence Thu 12 Jul 2018 8:01 Am

MIC.0001.0001.0210 Verbal Behaviour Assessment (And Acfi 08) - Bertha Aalberts (17)

MIC.0001.0001.0212 Toileting Assessment (And Acfi 04) - Bertha Aalberts (17)

MIC.0001.0001.0214 Speech And Comprehension Assessment - Bertha Aalberts (17)

MIC.0001.0001.0216 Sleep Assessment - Bertha Aalberts (17)

MIC.0001.0001.0229 Physical Behaviour Assessment (And Acfi 09) - Bertha Aalberts (17)

MIC.0001.0001.0231 Personal Hygiene Assessment (And Acfi 03) - Bertha Aalberts (17)

MIC.0001.0001.0436 Continence Assessment (And Acfi 05) - Bertha Aalberts (17)

MIC.0001.0001.0429 Wound Assessment And Management Plan - Bertha Aalberts (17)

MIC.0001.0001.0218 Skin Assessment - Waterlow - Bertha Aalberts (17)

MIC.0001.0001.0233 Pain Assessment Management And Flow Chart - Bertha Aalberts (17)

MIC.0001.0001.0238 Nutrition Assessment (And Acfi 01) - Bertha Aalberts (17)

MIC.0001.0001.0241 Medication Assistance Assessment (And Acfi 11) - Pre-January 2017 - Bertha Aalberts (17)

MIC.0001.0001.0243 Hearing Assessment - Bertha Aalberts (17)

MIC.0001.0001.0373 Complex Care Directives - Bertha Aalberts - Location Delp - Room No 17

MIC.0001.0001.0175 Bertha Aalberts - Diagnoses/Problems

MIC.0001.0001.0283 Discharge Summary - Bertha Aalberts - Pph Mrn Mq00110542 - Admission No Aq2330280

166

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

MIC.5000.0001.3367 Staffing Roster - Ppe 22072018.Pdf

MIC.0001.0001.0247 Continence Assessment (And Acfi 05) - Bertha Aalberts (17)

MIC.0001.0001.0226 Physiotherapy Assessment - Bertha Aalberts (17)

MIC.0001.0001.0245 Falls Risk Assessment Tool (Frat) - Bertha Aalberts (17)

CTH.4007.9000.0369 Falls Risk Assessment Tool, Continence Assessment, Chemosensory Loss Assessment - 02/08/2018 - 06/08/2018

MIC.0001.0001.0145 Wound Assessment And Management Plan (Laceration On Top Of Left Ear) - Bertha Aalberts (17)

MIC.0001.0001.0201 Chemosensory Loss Assessment - Bertha Aalberts (17)

CTH.4007.9000.0303 Wound Assessment And Management Plans - 06/08/2018 -07/08/2018

MIC.0001.0001.0149 Wound Assessment And Management Plan (Shin On Lower Right Leg) - Bertha Aalberts (17)

MIC.0001.0001.0153 Wound Assessment And Management Plan (Left Shin) - Bertha Aalberts (17)

MIC.0001.0001.0157 Wound Assessment And Management Plan (Sacral Pressure Inj) - Bertha Aalberts (17)

MIC.0001.0001.0193 Care Plan - Bertha Aalberts (17)

MIC.0001.0001.0239 Mobility Assessment (And Acfi 02) - Bertha Aalberts (17)

MIC.0001.0001.0256 Massage/Skincare Chart - Bertha Aalberts - Room No 17

MIC.0001.0001.0271 Mrs Bertha Aalberts - 1105 Frankston Dandenong Road Carrum Downs Vic 3201 - Folio 11.8505671 - Ur

MIC.0001.0001.0349 Aged Care Funding Instrument - Application For Classification - Effective From 1 January 2017 - Section 1 Particulars Of Person Being Appraised - Bertha Aalberts

MIC.0001.0001.0372 Checklist Must Be Completed - Bertha Aalberts Rm 17

MIC.0001.0001.0375 Wound Assessment And Management Plan (Shin On Lower Right Leg) - Bertha Aalberts (17)

MIC.0001.0001.0379 Wound Assessment And Management Plan (Right Heel) - Bertha Aalberts (17)

MIC.0001.0001.0382 Wound Assessment And Management Plan (Sacral Pressure Inj) - Bertha Aalberts (17)

JAA.0001.0002.0028 Beleura Hospital Notes

MIC.5001.0001.0526 Internal Emails Re: Beth Aalberts

MIC.0001.0001.0035 Email Correspondence Between Johanna Aalberts And Micare

CTH.4007.9000.0001 Submission From Aged Care Complaints Scheme

MIC.0001.0001.0366 Mobility Assessment (And Acfi 02) - Bertha Aalberts (17)

MIC.0001.0001.0374 Case Notes - Bertha Aalberts (17)

JAA.0001.0002.0001 Avondrust Nursing Notes - As Sent To Beleura

MIC.5001.0001.0529 Emails Re Beth Aalberts

MIC.5001.0001.0527 Internal Emails Fw: Beth Aalberts

MIC.0001.0001.0042 Internal Emails Regarding Beth Aalberts

167

Appendix 4 Exhibits

Exhibit Document

Exhibit

Number Number

CTH.1013.1004.0434 Letter From Aged Care Complaints Commissioner To Australian Aged Care Quality Agency Regarding Type 2 Referral - Micare Avondrust Lodge

MIC.5000.0001.3172 Progress Notes.Pdf

MIC.5001.0001.0830 Fw: Bertha Alberts

CTH.1013.1002.0003 Review Audit 16/08/2018

MIC.5000.0001.3115 Re: Avondrust Visit

CTH.4007.1000.0782 Audit Report: Micare Avondrust Lodge

MIC.0001.0001.0066 Consolidated Progress Notes - Bertha Aalberts

MIC.5000.0001.3364 Staffing Roster - Ppe 19082018.Pdf

JAA.0001.0003.0001 Death Certificate

MIC.5000.0001.2598 Med Chart And Bloods.Pdf

MIC.5000.0001.3166 Charts Results.Pdf

CTH.4007.1000.2849 Review Audit Assessment Information

CTH.4007.1000.5247 Review Audit Report

CTH.1013.1004.1098 Department Of Health Email Regarding Sanctions Under Consideration: Approved Provider Micare Ltd In Respect Of Micare Avondrust Lodge

MIC.5001.0001.0175 Re: Care Plan Reviews

MIC.5000.0001.2800 29.08.2018 - Ndis - Micare Avondrust Lodge.Doc.Pdf

MIC.5000.0001.0760 Email Re: Sanctions

MIC.5000.0001.3365 Staffing Roster - Ppe 02092018.Pdf

CTH.4007.1000.1471 Aacqa Assessment Contact Report - Avondrust

CTH.4007.2000.0163 Aacqa Published Decision - Avondrust

MIC.5000.0001.3398 Care Pathway Wound Management

MIC.5000.0001.3404 Care Pathway Assessment Of Possible Infection

MIC.5000.0001.3422 Care Pathway Warfarin

CTH.1013.1004.2620 Aacqa Decision To Vary - Avondrust

CTH.4007.1000.0513 Email From Aged Care Quality Agency To Micare

CTH.4007.1000.0517 Decision Following A Review Audit

CTH.4007.1000.5239 Review Audit Decision And Statement Of Reasons

MIC.5000.0001.2638 Presentation 11.9.Pdf

CTH.1013.1004.2880 Correspondence From Ansell Strategic To Department Of Health

MIC.5000.0001.3194 180830 Avondrust 3167 Micare Unmet Outcomes Audit Response.Docx

CTH.4007.1000.0548 Letter To Micare From The Aged Care Quality Agency Regarding Findings Of Failure And Possible Serious Risk To The Safety, Health Or Wellbeing Of A Care Recipient

CTH.4007.1000.0546 Email To Micare From The Aged Care Quality Agency Regarding Findings Of Failure And Possible Serious Risk To The Safety, Health Or Wellbeing Of A Care Recipient

168

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

CTH.1013.1004.2881 Micare Nurse Advisor And Administrator Sanctions Progress Report

CTH.1013.1004.2998 Aacqa Serious Risk Report - Avondrust

CTH.4007.1000.0686 Email From Micare To The Quality Agency

CTH.4007.1000.0687 Micare Avondrust Lodge (Racs Id 3167) Continuous Improvement Plan – Sanctions Rectification

CTH.1013.1004.3282 Aacqa Assessment Contact Report - Avondrust

CTH.4007.1000.1638 Aacqa Assessment Contact Advice - Avondrust

MIC.5001.0001.0512 Re: Aged Care Complaints Commissioner Case Id S19/001859 [Sec=Unclassified]

MIC.5001.0001.0513 Re: Print Screen Of Weight Chart B. Aalberts

MIC.5001.0001.0514 Print Screen Of Weight Chart B. Aalberts

MIC.5001.0001.0515 Copy Of Avondrust Lodge - Monthly Weight Chart 2018.Xlsx

MIC.5001.0001.0516 Internal Emails Re Aalberts

MIC.5001.0001.0507 Phone Conference With Jillian Re Aalberts

MIC.5001.0001.0508 Re: Print Screen Of Weight Chart B. Aalberts

CTH.4007.9000.0597 Email From Jillian Bradtke To Petra Neeleman, Micare

CTH.4007.9000.0689 Micare Memo

MIC.0001.0001.0065 Email From Micare To Jan Rice

MIC.5001.0001.0393 Aged Care Complaint Commissioner Case Ids19/003117

MIC.5001.0001.0396 Fw: Aged Care Complaints Commissioner [Sec=Unclassified] Aalberts

MIC.5001.0001.0488 Re: Aged Care Complaints Commissioner [Sec=Unclassified] Aalberts

MIC.5000.0001.2930 Lb Jan Rice Response.Pdf

CTH.4007.9000.0713 Email From Jillian Bradtke To Petra Neeleman, Micare

MIC.5001.0001.0485 Fwd: Re Aalberts [Sec=Unclassified]

CTH.4007.1000.5267 Decision To Publish Serious Risk Of Information

CTH.4007.9000.0742 Email From…, Aged Care Complaints Commissioner,…, AACQA

MIC.5000.0001.3440 Policy 2.8 Pain Management.Docx

CTH.4007.1000.1117 Assessment Contact Report: Micare Avondrust Lodge

CTH.4007.1000.1201 Aacqa Assessment Contact Advice - Avondrust

CTH.4007.1000.2661 Assessment Contact Advice

CTH.1013.1004.3226 Department Of Health Notice Of Non-Compliance With Accreditation Standards

CTH.1013.1004.3401 Micare Avondrust Lodge Nurse Advisor And Administrator Report

CTH.4007.1000.0802 Email Correspondence Between Aged Care Complaints Commissioner And Aged Care Quality Agency

CTH.4007.9000.0746 Type 1 Referral (Relevant Issue/Concern) For Avondrust From Aged Care Complaints Commissioner To AACQA

169

Appendix 4 Exhibits

Exhibit Document Number Number

Exhibit

CTH.4007.1000.2791 Assessment Contact Report

CTH.1013.1004.3897 Notice To Remedy Non-Compliances

MIC.5000.0001.1242 Board Report - Residential.Docx

CTH.4007.1000.1946 Record Of National Line Call

CTH.1013.1002.0574 Assessment Contact Report

CTH.1013.1004.4188 Assessment Contact Advice: MiCare Avondrust Lodge

MIC.5001.0001.0935 181029 Physio Action Plan.Docx

CTH.4007.1000.1204 Aacqa Audit Report - Avondrust

CTH.4007.2000.0058 Assessment Contact Report

CTH.1013.1004.5043 Assessment Contact Advice: Miccare Avondrust Lodge

MIC.5000.0001.3473 Care Pathway Falls Assessment & Management

CTH.4007.1000.5272 Site Audit Report

CTH.4007.2000.0632 Aacqa Evidence Record - Site Audit - Avondrust

MIC.5000.0001.0067 11.01.2018 – Notice Of Decision To Lift Sanctions (Signed) - Micare Avondrust.Pdf

MIC.5000.0001.0068 11.01.2018 – No Further Action (Signed) – MiCare Avondrust.Pdf

MIC.5000.0001.2818 1901 Board Report.Docx

MIC.5000.0001.0912 Email Re: Stupidity

MIC.5000.0001.3401 Care Pathway Pain

MIC.5000.0001.3464 Care Pathway Hypoglycaemia

MIC.5001.0001.0397 Mini Nutritional Assessment.Pdf

MIC.5001.0001.0399 Policy 2.10 Nutrition And Hydration P&P.Docx

CTH.4007.2000.0140 Aacqa Decision To Re-Accredit Following Site Audit - Avondrust

MIC.5001.0001.0107 Re-Accreditation Decision To Re-Accredit

MIC.5000.0001.1247 Micare Ltd Covering Letter 8.2.19.Pdf

MIC.5000.0001.1248 Appendix 1 Avondrust Lodge.Pdf

MIC.5000.0001.1251 Appendix 2 Avondrust Lodge.Pdf

MIC.5000.0001.1254 Avondrust Lodge Final 8.2.19.Pdf

MIC.5000.0001.0752 13022019 Potential Sanctions Causation Report Draft.Pdf

MIC.5000.0001.1494 Response Avondrust Rc.Doc

CTH.4007.1000.3407 Compliance Update

MIC.5000.0001.3447 Competency Medication Yearly Review

MIC.5000.0001.3462 Competency Neuro Obs

CTH.4007.9000.0966 Aged Care Complaints Commissioner - Detailed Resolution Report

CTH.4007.9000.1005 Aacqa - Notification To Complainant On Resolution Process

MIC.5000.0001.2599 Finalisation Letter Micare.Pdf

CTH.4007.3000.0001 Briefing Note – Avondrust – Acqsc Consolidated Notes

MIC.5000.0001.3380 Staffing Roster Ppe 27052018.Pdf

MIC.5000.0001.3381 Staffing Roster Ppe 05082018.Pdf

170

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Exhibit Document

Exhibit

Number Number

WIT.0260.0003.0001 Supplementary Statement Of Petronella Neeleman

WIT.0260.0004.0001 Supplementary Statement Of Robert Van Duuren

RCD.9999.0120.0001 Agreed Chronology

RCD.9999.0120.0007 Correspondence From Royal Commission To Micare Dated 8 July 2019

RCD.9999.0120.0005 Screenshots Of Micare’S Website - Eden Alternative

MIC.5000.0001.1471 Minutes Of Meeting [Tab 4 Of Board Paper Bundle]

MIC.5000.0001.0356 Board Meeting Agenda [Tab 10 Of Board Paper Bundle]

MIC.5000.0001.0143 Board Papers [Tab 15 Of Board Paper Bundle]

MIC.5000.0001.0944 Board Papers [Tab 18 Of Board Paper Bundle]

MIC.5000.0001.3310 Micare Board Governance Review [Tab 21 Of Board Paper Bundle]

SUB.0001.0038.2248 Appendix 1 Avondrust Lodge

SUB.0001.0038.2255 Avondrust Lodge Final 8.2.19

JAA.0001.0004.0002 Photograph – Beth, First Day

RCD.0003.0278.0001 Ntg-0278

6-36 WIT.0220.0001.0001 Statement of Johanna Aalberts-Henderson

6-37 WIT.0260.0001.0001 Statement of Robert Van Duuren

6-38 WIT.0260.0004.0001 Supplementary Statement of Robert Van Duuren

6-40 WIT.0293.0001.0001 Additional Statement of Jan Rice

6-42 WIT.0260.0003.0001 Supplementary Statement of Petronella Dorothea Neeleman

MIC.5000.0001.0832 Board Papers [Tab 8 Of Board Paper Bundle]

MIC.5000.0001.1242 Extract To Be Inserted Into November 2018 Report, Regarding Avondrust Non-Compliance [Tab 13 Of Board Paper Bundle]

MIC.5000.0001.0758 Minutes Of Meeting [Tab 16 Of Board Paper Bundle]

MIC.5000.0001.2818 Non-Compliance Insert [Tab 20 Of Board Paper Bundle]

SUB.0001.0038.2246 Micare Ltd Covering Letter 8.2.19

SUB.0001.0038.2252 Appendix 2 Avondrust Lodge

JAA.0001.0003.0006 Photograph – Beth, Johanna And Ruth

JAA.0001.0004.0001 Photograph – Beth And Johanna

RCD.0003.0293.0001 Ntg-0293

6-39 WIT.0278.0001.0001 Statement of Jan Rice

6-41 WIT.0260.0002.0001 Statement of Petronella Dorothea Neeleman

171

Appendix 4 Exhibits

Day 37 – 16 July 2019

Exhibit Number Document Number

Exhibit

6-43 WIT.0215.0001.0001 Statement of Nicholas Micael Zane Hall

6-44 WIT.0216.0001.0001 Statement of Timothy John Deverell

6-46 WIT.0202.0001.0001 Statement of Maggie Beer

6-48 WIT.0204.0002.0001 Corrigendum to Statement of Sandra Iuliano

6-50 WIT.0246.0001.0001 Statement of Adrienne Alexis Lewis

Day 38 – 17 July 2019

Exhibit Number Document Number

Exhibit

6-51 WIT.0266.0001.0001 Statement of Elsie Marion Scott

6-52 WIT.0275.0001.0001 Statement of Lisa Jayne Jones

6-54 WIT.0208.0001.0001 Statement of FA

6-56 WIT.0237.0001.0001 Statement of Angela Raguz

6-57 WIT.0192.0001.0001 Statement of Drew Darren Dwyer

6-58 WIT.0193.0001.0001 Statement of Dr. Jennifer Ann Abbey

6-45 WIT.0270.0001.0001 Statement of Lindy Maree Twyford

6-47 WIT.0204.0001.0001 Statement of Sandra Iuliano

6-49 WIT.0205.0001.0001 Statement of Dietitians Association of Australia

6-53 WIT.0172.0001.0001 Statement of Natasha Jane Chadwick

6-55 WIT.0191.0001.0001 Statement of Sandy Marie Green

173

Appendix 5: Post-hearing Submissions

175

Appendix 5: Post-hearing Submissions

Adelaide Hearing 2

Submission Date Submitted

Post-Hearing statement of BC 13 March 2019

Submissions of KinCare Health Services Pty Ltd 29 March 2019

Post-Hearing statement of Peter John Vincent (redacted version) 29 March 2019

Submissions of the Commonwealth – Hearing 2 29 March 2019

Sydney Hearing

Submission Date Submitted

Garden View Case Study submissions of Counsel Assisting 31 May 2019

Brian King Gardens Case Study submissions of Counsel Assisting 31 May 2019

Bupa Willoughby Case Study submissions of Counsel Assisting 31 May 2019

Submissions of Reeves family in relation to Garden View Case Study heard in Sydney on 6 and 7 May 2019 7 June 2019

Columbia Aged Care response to Oberon Village Case Study submissions 7 June 2019 of Counsel Assisting dated 31 May 2019

Garden View Case Study submissions on behalf of Dr Miles Burkitt and Dr Kenneth Wong 11 June 2019

Brian King Gardens Case Study submissions on behalf of Dr Ginger 11 June 2019

Submissions on the Sydney Hearing by the Commonwealth as represented by the Department of Health and the Aged Care Quality and Safety Commission 11 June 2019

Submissions of Garden View Aged Care Pty Limited in response to submissions 14 June 2019 of Counsel Assisting

Brian King Gardens case study submissions for Anglican Community Services 14 June 2019

Submissions of Bupa Aged Care Australia Pty Ltd in response to Counsel 14 June 2019 Assisting’s submissions dated 31 May 2019 regarding the Bupa Willoughby Case Study

Submissions of Garden View Aged Care Pty Limited in response to submissions of Reeves family 20 June 2019

Oberon Village Case Study submissions of Counsel Assisting 31 May 2019

Submissions of Counsel Assisting in relation to selected expert and 3 June 2019 policy matters

176

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Perth Hearing

Submission Date Submitted

Submissions of Counsel Assisting – Japara Mitcham Case Study 5 July 2019

Submissions of Counsel Assisting – Alkira Gardens Case Study 5 July 2019

Submissions of Japara 12 July 2019

Submissions of Our Lady of China 12 July 2019

Darwin Hearing

Submission Date Submitted

Written submissions of IRT WBG in reply: IRT William Beach Gardens 24 July 2019 Case Study

Written submissions of Dr Bird in reply: IRT William Beach Gardens Case Study 24 July 2019

Written submissions of Counsel Assisting the Royal Commission: 24 July 2019 IRT William Beach Gardens Case Study

Written submissions of Counsel Assisting the Royal Commission: Assisi Centre Limited (Assisi) Case Study 24 July 2019

Written submissions of Assisi in reply: Assisi Case Study 31 July 2019

Written submissions of Dr Tay in reply: Assisi Case Study 1 August 2019

Supplementary written submissions of Assisi: Assisi Case Study 9 August 2019

Cairns Hearing

Submission Date Submitted

Written submissions of Counsel Assisting the Royal Commission: 24 July 2019 Avondrust Case Study

Written submissions of MiCare in reply: Avondrust Case Study 31 July 2019

Appendix 6 Service Provider Visits

177

Appendix 6: Service Provider Visits

179

Appendix 6: Service Provider Visits The Commissioners have visited a number of service providers around Australia to

gain an understanding of a range of services to older people. Commissioners will continue to conduct service provider visits over the remainder of the Royal Commission.

The visits to services have enabled the Commissioners to see a range of different care settings and services to older people. The range of services visited include large and small providers; mainstream, specialist and innovative services; and residential, home care and respite services.

The selection of a service for a visit does not reflect any judgement, positive or negative, about the safety and quality of a service.

Aged Care Service Visits

Date Service Provider Location

26/2/19 Dudley Foord House Anglicare The Ponds, Sydney,

Woodbury Village NSW

Winston Hills, Sydney,

NSW

26/2/19 Residential Cottage (home care) Group Homes Australia St Ives, Sydney, NSW

28/2/19 Our Lady of Consolation Catholic Healthcare Rooty Hill, Sydney, Aged Care and Services- Respite NSW

and Wellness Centre (residential and community care)

28/2/19 Kincare home care services Kincare Bella Vista, Sydney,

NSW

1/3/19 HammondCare Hammondville HammondCare Hammondville, Sydney, NSW

4/3/19 Virtual Dementia Experience Dementia Australia Parkville, VIC

5/3/19 Strathdon Community Nursing Home Uniting Agewell Forest Hill, Melbourne, Strathdon Community Aged Care VIC

services (homecare)

5/3/19 Port Melbourne Hostel Wintringham

Specialist Aged Care

Port Melbourne, Melbourne, VIC

8/3/19 Smorgon Nursing Home Jewish Care South Melbourne,

Montifiore Nursing Home Victoria Melbourne, VIC

Senior Living Precinct

180

Royal Commission into Aged Care Quality and Safety Interim Report Volume 3

Aged Care Service Visits

Date Service Provider Location

28/5/19 Aboriginal Elders Village Aboriginal

Community Care Davoren Park, SA

20/6/19 Bidyadanga Health Clinic Kimberley Bidyadanga, WA

Aboriginal Medical service

20/6/19 Kimberley Aged and Community Services, including Home and Community Care (HACC) Centre

Western Australian Country Health Service

Bidyadanga, WA

21/6/19 Germanus Kent House Southern Cross Broome, WA

Bran Nue Day Respite and Breakfast Care WA Club

21/6/19 Royal Flying Doctor Service Broome base Royal Flying Doctor Service

Broome, WA

10/7/19 Juninga Nursing Home Australian Regional Coconut Grove,

Juninga Independent Living Units and Remote Darwin, NT (home care) Community

Services

16/7/19 Mercy Place Retirement Village Home Mercy Place Westcourt Home Care Mercy Health Westcourt, Cairns, QLD

18/7/19 Regis Kirwan Regis Aged Care Kirwan, Townsville,

QLD

19/7/19 Carinity Fairfield Grange Aged Care Carinity Idalia, Townsville, QLD

23/7/19 Elizabeth Lodge Anglicare Rushcutter’s Bay,

Sydney, NSW

31/7/19 Regis Ontario Regis Aged Care Mildura, VIC

13/8/19 Balaklava Mill Court Homes Balaklava Mill Court Balaklava, SA Homes

13/8/19 Kiandra Residential Aged Care Rosha Group Prospect, Adelaide, SA

21/8/19 Bupa Modbury Bupa Modbury, Adelaide, SA

21/8/19 Northgate House SA Department

for Health and Wellbeing

Northgate, Adelaide, SA