| Lakeshore Care Centre - Complaint Information |
| General Details | |
|---|---|
| Facility Type | Residential Care (Hospital Act) - 400 |
| Investigation Completed | May 12, 2021 |
| Reason for Investigation | - Policies and procedures - Care and supervision - Nutrition and food services |
| Report of Findings |
|---|
| On March 1, 2020, Licensing received a complaint alleging concerns regarding Care and Supervision. The allegations included the following details: - Inadequate care following surgery - Inadequate supervision - Care plan was not followed - Policies and Procedures were not followed - Inadequate communication with the person in care’s representative All areas of the complaint were fully investigated. Evidence was received and reviewed through interviews, communications and consultation with facility management, and a review of documentation. The following contraventions were determined: - Residential Care Regulation Section 82 – Implementation of Care Plans - Residential Care Regulation Section 85(1)(d) – Policies and Procedures - Residential Care Regulation Section 63(3)(a) – Food Preparation and Service - Residential Care Regulation Section 81(4)(b)(i) – Care Plan - Community Care and Assisted Living Act Section 7 (1)(b)(i) and (ii) – Standards to Be Maintained: Schedule 2.(a) Rights to Health, Safety and Dignity and Schedule 3.(f) Rights to Participation and Freedom of Expression - Residential Care Regulation Section 77(2)(b) and (c). |
| Substantiated Contraventions: Evidence for this summary report is based on a combination of the Licensing Officer’s observations, a review of facility records and information provided by the facility staff at the time of the investigation. |
| Observed Violations/Contraventions: A summary of the violations found during the complaint investigation are listed below. |
| Code | Category/Description |
|---|---|
| 33280 - RCR s.85(1)(d) | A licensee must do all of the following: (d) ensure that policies are implemented by employees. Observation: Staff did not document reasons for not following a care plan or reasons for removing a person in care from the dining area. Corrective action: The licensee has been asked to submit a corrective action plan. |
| 34320 - RCR s.63(3)(a) | A licensee must ensure that meals are provided (a) in a dining area. Observation: A person in care was unreasonably denied access to the dining hall. Corrective action: The licensee has been asked to submit a corrective action plan. |
| 34750 - RCR s.81(4)(b)(i) | A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care. Observation: A person in care repeatedly defeated a safety device but the care plan was not amended to address this safety risk. Corrective action: The licensee has been asked to submit a corrective action plan. |
| 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: Staff did not follow a care plan relative to fall injury prevention. Corrective action: The licensee has been asked to submit a corrective action plan. |
| 34950 - CCALA s.7(1)(b)(i) | A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care, Observation: Without consideration to alternative, more safe measures, a person in care was unjustifiably provided meals in an area less supervised than the dining area and with less social interaction. Corrective action: The licensee has been asked to submit a corrective action plan. |
| 39080 - RCR s.77(2)(b) | Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (b) the medical practitioner or nurse practitioner responsible for the care of the person in care. Observation: Staff did not immediately inform the physician that a person in care was involved in a reportable incident. Corrective action: The licensee has been asked to submit a corrective action plan. |
| 39090 - RCR s.77(2)(c) | Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer. Observation: Three reportable incidents were not reported and one reportable incident contained incorrect information which could potentially affect decisions made by the licensing officer. Corrective action: The licensee has been asked to submit a corrective action plan. |
| 40140 - CCALA s.7(1)(b)(ii) Schedule 1-3(f) | To have his or her family or representative exercise the rights under this clause on his or her behalf. Observation: A person in care's behavior resulting in risk of injury, their removal from the dining area and changes to medication were not communicated to the person in care's representative. Corrective action: The licensee has been asked to submit a corrective action plan. |
| Actions Required by Licensee/Operator | |
|---|---|
| - The licensee has been requeestted to submit a corrective action plan for review. |
| Action Required by Licensing Officer or Medical Health Officer | |
|---|---|
| - A requested corrective action plan will be reviewed to determine whether all contraventions have been addressed. |
| Status Update |
|---|
| No further action required. All contraventions have been addressed. |
| Updated on May 25, 2021. |
