CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: During a review of 7 PIC's chart, the following was noted:
- 6 constipation pathway charts contained numerous instance of missing documentation between the months of August 2017 and November 2017.
- 7 wound care charts were reviewed between the months of October 2017 and November 2017. There were 48 instances of missing documentation during this time (this is a repeat contravention from the previous routine inspection).
As a result it is unclear is the care being provided was consistent with the terms of the care plan.
Corrective Action(s): Please ensure that all documentation is completed as required and that the care and supervision of the PIC's is consistent with the terms and conditions of the care plans.
Please provide licensing with a wound care monitoring plan that is approved by the facility wound care clinician and that outlines who will monitor the plan for ongoing effectiveness, implementation and completion.
Date to be Corrected: Feb 28 2018
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: A review of a communal fridge found 1 expired bottle of vinegar. The manager stated that although the vinegar belonged to a PIC the activity staff are responsible for monitoring the expiry dates of the items in the fridge.
Corrective Action(s): Please ensure that all food is stored safely
Date to be Corrected: Feb 28 2018
RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: A review of 7 PIC's charts found that one contained no record of TB and immunization status.
Corrective Action(s): Please ensure that, for all PIC's, a record is kept of TB and immunization status.
Date to be Corrected: Feb 28 2018
RECORDS AND REPORTING: 39190 - RCR s.78(2)(a) - A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care.
Observation: A review of 7 PIC's MAR's found 3 instances of missing documentation in the regular medications.
Corrective Action(s): Please ensure that a record is kept of all medications administered to the PIC's.
Date to be Corrected: Feb 28 2018
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: A review of the 2017 weight charts for 2 neighbourhoods found 32 missing weight records with no explanation as to why they had been missed.
Corrective Action(s): Please ensure that each PIC is weighed at least once each month
Date to be Corrected: Feb 28 2018
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