PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31240 - RCR s.21(a) - A licensee must ensure that all furniture and equipment for use by persons in care (a) meet the needs of the persons in care.
Observation: A licensee must provide communication devices that are appropriate for the needs of a person in care (PIC) and enable her or him to communicate with staff. A PIC was unable to use a signaling device to alert staff in their room, as the signaling device was outside of their reach. In other words, the communication device was not meeting the needs of this PIC.
Corrective Action(s): Please ensure that equipment used by PICs meet their needs, including the placement of communication devices so these devices can be used to signal a staff that a PICs needs immediate assistance.
Date to be Corrected: April 1, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: Two labelled medicated creams were stored in two bathroom cabinets (one medicated cream per room).
Corrective Action(s): Please ensure that medications are securely stored.
Date to be Corrected: April 8, 2022
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: The Licensee's policy and procedure required a wandering assessment prior or on admission. While the Licensee completed a behavioural assessment on admission, this assessment did not include evidence of a wandering assessment for all persons.
The Licensee's policy and procedure required staff to keep a record of baths or showers completed. Staff were not completing this record. It was also confirmed that staff were not consistent in documenting information regarding the completion of ADLs (range of completion varied between 10 and 90 percent for different persons and ADLs.)
Corrective Action(s): Please ensure that staff implement the policies and procedures of the Licensee, including the documenting of baths/showers completed and the completion of other ADLs.
Date to be Corrected: April 8, 2022
CARE AND/OR SUPERVISION: 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 PIC was at high risk for falls and had a fall mat beside their bed, but this person’s care plan did not identify that they required one. A second person’s care plan documented that they required a fall mat, but no fall mat was in the room.
Corrective Action(s): Please ensure that care plans are reviewed and, if necessary, revised due to changes in circumstances.
Date to be Corrected: April 8, 2022
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: A PIC's Nutritional Care Plan documented that they had a textured diet and an allergy to a certain type of snack food. The PIC's nightstand and top of dresser included two different items of this snack food. Weight of the items was approximately .25 to .5 kg in weight. The snack food was not consistent with the textured diet and there was no evidence that the dietitian had assessed the risk.
Corrective Action(s): Please ensure that the care and supervision of persons in care is consistent with the information included their plan of care.
Date to be Corrected: April 8, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Six PICs files were reviewed and one PIC’s file included no evidence of compliance with the TB control program. A blank TB form on the PIC’s file and no other evidence.
Corrective Action(s): Please ensure that PIC’s file includes compliance with the TB control program. This evidence must be obtained prior or on admission.
Date to be Corrected: April 8, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: servery area included a refrigerator, microwave, toaster, etc. The following was observed: Cold toast in the toaster, a plate full of cold bagels (8+) in the microwave, 3 unlabeled bowls of unlabeled porridge in the fridge, an unlabeled plate of toast/jam in the fridge, and 3 uncovered glasses of juice in the fridge.
Corrective Action(s): Please ensure that foods and liquid refreshments are safely stored and handled.
Date to be Corrected: April 8, 2022
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(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: Six PICs files were reviewed for a one-year period. Weights were not recorded for at least one month for six PICs. One PICs file did not include a record for three months and a second PICs file did not include a record for 6 months.
Corrective Action(s): Please ensure that PICs are weighed at least once per month.
Date to be Corrected: April 8, 2022
|