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 person in care room had paint peeling visibly on two spots of one wall.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: January 5, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: One bedroom requires cleaning - the rug was dirty and areas of bedroom floor had build up of dust.
Corrective Action(s): Ensure all rooms and common areas are maintained in a clean condition.
Date to be Corrected: January 5, 2018
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Review of staff records list, one employees performance review has not been completed since 2013. Discussion with the manager is these are done at a minimum every two years.
Corrective Action(s): Ensure regular performance reviews to ensure that the employee continues to meet the requirements of this regulation.
Date to be Corrected: January 5, 2018
STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Please see code 32100 - RCR s.40(1)(a)
Corrective Action(s):
Date to be Corrected:
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: For one person in care, it was observed that two PRNs that were administered were not documented on the Medication administration records (MARs). Another PRN result was documented but not signed on the MAR. As well, this person's medication administration for one shampoo was not followed as per the MAR. The manager identified some changes did occur over time and this medication required potentially more frequent administration than what is prescribed.
Review of three person in care MARs, a total of 6 signatures were missed one the adminstration record. In addition, staff have not completed the Med Error report as required when there is a missed signature for medication administered.
Corrective Action(s): Ensure staff comply with the policies of the medication safety and advisory committee.
Date to be Corrected: January 5, 2018
CARE AND/OR SUPERVISION: 34640 - RCR s.81(3)(c)(i) - A care plan must include all of the following: (c) a nutrition plan that (i) assesses a person in care's nutrition status.
Observation: The food and nutrition forms and screening forms have not been completed for all persons in care. The manager, although aware of exactly which forms licensing was refering to was unable to locate any prior copies.
Corrective Action(s): Ensure assessments are completed to ensure the person in care's nutritional status have been appropriately assessed and determination has been made if the person in care requires referral to the dietician.
Date to be Corrected: January 5, 2018
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: As per RCR s.68(4), there was a change in how staff were administering one person's medication. This change was not updated in the care plan, and nor was it discussed with the pharmacy or physician.
Corrective Action(s): Ensure changes are updated in the care plan.
Date to be Corrected: January 5, 2018
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: Please See code 39320 RCR s.83(4)(a)
Corrective Action(s):
Date to be Corrected:
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (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: In a review of three persons weight records, one person was not weighed for one month of this year and a reason was not documented.
Corrective Action(s): Ensure each person in care is weighed monthly.
Date to be Corrected: January 5, 2018
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