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: Review of the Medication Administration Records (MAR) found that two medications that had been dispensed had not be initialed for, as required by the facilities medication policies and procedures.
Review of 5 PIC care plans found that 1 PIC kardex did not capture the fall risk that was identified in the care plan but it appeared that fall prevention strategies were in place. 1 PIC's bath day was identified as Saturday in the care plan but the bath day was confirmed as Saturday in the bath calendar and on the kardex.
Corrective Action(s): Ensure that policies are implemented by employees.
Date to be Corrected: CORRECTED AT TIME OF INSPECTION.
CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Observation: A review of the facility's master PIC weight printout (supplied by the dietician) found that there were 19 missing weights for 13 PIC's in the facility . There was no documentation in the progress notes or on the handwritten weight sheets why the PIC's could not be weighed or why the weight was not recorded. It was noted that any changes in weights were captured and addressed.
Corrective Action(s): Ensure that if a PIC is refuses or is unable to be weighted, that the licensee must record in the nutrition plan the reason why the person in care was not weighted.
Date to be Corrected: January 8, 2018
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: Review of 1 of 3 medication carts found that one herbal medication had not been dispensed by the facilities pharmacy.
Corrective Action(s): Ensure that a pharmacist packages all medication.
Date to be Corrected: January 8, 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: Review of 1 of 3 medication carts, found one medication that had expired.
Corrective Action(s): Ensure that all expired medications are returned to the dispensing pharmacy.
Date to be Corrected: January 8, 2018
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