PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31070 - RCR s.16(2)(a) - A licensee must ensure that each bedroom, bathroom and common room is lit sufficiently to (a) permit a person to carry out effectively the types of activities that would be reasonably expected in the ordinary use of the room.
Observation: In 1 of 4 bathrooms, the lighting was not sufficient for the persons utilizing this bathroom. The Manager of Care checked the bulbs and 2 were not working, 1 was not screwed in appropriately and 1 was flickering. It was stated by 1 person in care that it was unscrewed by staff.
Corrective Action(s): Ensure lighting is sufficient in bathrooms for persons to safely use the bathrooms.
Date to be Corrected: April 6, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: 4 of 4 areas that were checked for appropriate water temperatures, exceeded the 49 degrees Celsius maximum by atleast 2 degrees and up to 53.4 degrees Celsius.
Corrective Action(s): Ensure that water accessible to persons in care, is not heated to more than 49 degrees Celsius.
Date to be Corrected: April 6, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: In 2 of 3 person in care's bedrooms, some furniture was difficult to open, hindering the ability of the person in care to utilize the furniture. For 1 of these 3 persons, one desk had a broken surface, exposing the particle board on the surface of the desk, making cleaning impossible and potential for splinters should the person in care happen to touch the area.
Corrective Action(s): Ensure person in care's furnishings are maintained in a good state of repair.
Date to be Corrected: April 6, 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 Medication Policies and procedures for Transfer of Function - there is no evidence to confirm that the procedures of this policy are being followed. This was confirmed by the Manager of Facility and Manager of Care.
Corrective Action(s): Ensure that the policies and procedures of the medication safety and advisory committee are complied with.
Date to be Corrected: April 6, 2018
STAFFING: 32340 - RCR s.70(2)(b) - A licensee must ensure that employees who store, handle or administer medication to persons in care (b) have successfully completed any training programs established by the medication safety and advisory committee
Observation: Upon review of the medication policies and procedures, review of delegation of task/transfer of function from nurse to non-professional staff to administer medication, discussion with the Manager of Care and Manager of facility, although it is stated that another company has taken over the staffing and the manager of care has only trained two staff since commencing her position, the manager of facility does not have any documentation to confirm that non-professional staff have been appropriately trained and delagated the task of administering medications.
Corrective Action(s): Ensure staff have successfully completed any training required to administer medications, with documentation in place to confirm successful training.
Date to be Corrected: April 6, 2018
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Upon review of the policies and procedures of the facility, it is noted that there are yearly reviews documented - the last being October 2017 by the Manager of Facility. Of concern, is the number of policies auditted which were requiring updates. The policies reviewed on day 2 of the inspection were: Medication policies, Fall Prevention, Reportable Incidents, Missing Persons, TB Guidelines, Immunization Guidelines, Nutrition Care and Services and Communicable Disease.
Corrective Action(s): Ensure policies are reviewed appropriately and revised to reflect current practice.
Date to be Corrected: April 6, 2018
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: In 1 of 3 care plans, the resident care monthly summary - was not completed as required.
Corrective Action(s): Ensure polices and procedures are implemented by staff
Date to be Corrected: April 6, 2018
|