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: A review of the physical facility found that two baseboards located on Webster's corner had black scuff marks along the entire board caused by wheelchairs.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: March 15, 2022
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: A random review of the medication administration records found that three entries had not been signed for. Discussion with the RCC advised that they have self-identified this issue and there is an auditing system in place.
Corrective Action(s): Please ensure all staff follow the policies and procedures developed by the Medication Safety and Advisory Committee (MSAC).
Date to be Corrected: March 15, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: The following observations were noted:
- Approximately 3-4 unlabelled shampoo and shaving cream was found in the tub room located on the neighbourhood.
- An unlabelled deodorant was found in the second tub room located on the neighbourhood.
Corrective Action(s): Ensure items are labelled or placed in an individual container for persons in care to maintain health and hygiene.
Date to be Corrected: March 15, 2022
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: During the medication review it was noted that three PRN medications had expired in January 2021, September 2021 and January 2022. Discussion with the manager confirmed there is an auditing system in place to prevent further occurrences.
Corrective Action(s): Ensure that medication found in the medication carts is audited regularly for expiration dates and returned to the pharmacy when the expiry date on the medication has passed.
Date to be Corrected: March 15, 2022
|