LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: Monitoring of the physical environment and the care and services provided by the facility have not been implemented as per the routine inspection compliance plan that was approved on April 22, 2022. This includes the following:
-Move in assessments, admission information, and valuable records continue to have incomplete information/documentation for new admissions
-Call bell response time audits are being printed, however there was no evidence as to how the call bell response times are being monitored. It was noted that there were multiple response times exceeding 15 minutes, and up to 1 hour or more to response to the call bell. The time frame reviewed was April 4-10th, 2022.
This is a repeat contravention.
Corrective Action(s): Please provide a detailed action plan to licensing as to how these areas of noncompliance will be addressed.
Date to be Corrected: May 17th, 2022.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: One bedroom had a pocket door (to the bathroom) that was damaged and could not slide easily on its tracks. The door frame around the door was missing trim, and appeared to have drywall damage. Of concern is that a PIC could potentially become trapped in the bathroom if they were able to close the door.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: May 6, 2022.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31580 - RCR s.30(a) - A licensee must ensure that all bathrooms have (a) a door, equipped with a lock that can be opened from the outside in the case of an emergency.
Observation: The licensee has an approved exemption from 2017, to remove the bathroom doors (for PICs who require mobility aids to access the bathroom, or a lift) and replace the bathroom doors with a curtain for ensure privacy and dignity. It was observed that 2 rooms had the bathroom doors removed, and no curtain in place. In a 3rd room the door had been removed and replace with a curtain despite the PIC not meeting the criteria to have the door removed, as per the approved exemption. This was discussed and reviewed with the Director of clinical, quality, and education. The approved exemption also has a requirement to have the details of the exemption approval posted for all PICs and families to see, in a prominent area of the facility, this has not occurred.
Corrective Action(s): It is the licensee's responsibility to ensure that the details of the approved exemption plan is maintained.
Date to be Corrected: May 6, 2022.
CARE AND/OR SUPERVISION: 34690 - RCR s.81(3)(e)(iii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (iii) a plan for following up on any falls suffered by a person in care.
Observation: 8 PICs fall care plans were reviewed, at least 3 persons in care did not have a fall prevention plan which addressed how the follow up on any falls suffered by a person in care would be addressed, as per this RCR, and the facility's fall policy.
Corrective Action(s): Ensure all persons in care have a fall prevention plan which includes an assessment of the risk of falling, a prevention plan, and a plan for following up on any falls suffered by a person in care.
Date to be Corrected: May 17, 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: On review of 4 new admissions, all 4 PICs did not have evidence of compliance with Province's immunization program.
Corrective Action(s): Ensure that all persons admitted to a community care facility comply with the Province's immunization and TB control programs.
Date to be Corrected: May 17, 2022.
RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: Upon review of 4 new admissions to the facility, 1 person in care admitted more than 30 days ago did not have a care plan in place to guide staff to provide care to the person in care. The auto-fill information that requires staff input to address the individuals needs had not been completed in all areas related to care.
Corrective Action(s): Ensure that a person in care has a short term care plan in place for the first 30 days, and a detailed care plan to guide staff in all matters related to care, after 30 days.
Date to be Corrected: May 6, 2022.
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