PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: Inspection of the laundry facilities that are used by persons in care, found that the laundry facilities floor was not a slip resistant surface.
Corrective Action(s): Ensure that the laundry facilities used by persons in care has a slip resistant floor surface.
Date to be Corrected: January 22, 2018
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Review of the MAR's for 1 of 8 PIC's found that 1 PRN effectiveness result was documented on the back of the MAR and 7 effectiveness results were documented in the communication book for 12 administered PRN's. There was no documentation found recording the effectiveness results for 4 administered PRN's. Discussion with the Manager and staff determined that the facility MSAC policy states that the monitoring results of the PRN's can be recorded on the back of the MAR or in communication notes. The Manager stated that there are plans change the MSAC policy to document PRN effectiveness only on the back of the MAR.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the MSAC.
Date to be Corrected: January 22, 2018
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation (CORRECTED DURING INSPECTION): Review of the medication cabinet for 8 PIC's, found one prescribed topical had expired in May 2017 and had not been placed in the "return to pharmacy" container.
Corrective Action(s): Ensure that all PIC's expired medication is returned to the dispensing pharmacy.
Date to be Corrected: CORRECTED AT TIME OF INSPECTION.
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