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 Administration Record (MAR) determined that one PRN was given but not initialed on the MAR.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: August 8, 2016
POLICIES AND PROCEDURES: 33130 - RCR s.68(3)(a) - The medication safety and advisory committee must establish and review as required (a) training and orientation programs for employees who store, handle or administer medications to persons in care.
Observation: A review of the Medication Safety and Advisory Committee (MSAC) determined that there was no documentation provided by the pharmacist that reviewed or established training and orientation programs for employees who store, handle or administer medications to persons in care. Discussion with the Manager determined that this is reviewed at the MSAC meeting but there is no meeting minutes that document this.
Corrective Action(s): Ensure the MSAC establishes and reviews as required, training and orientation programs for employees who store, handle and administer medications to persons in care.
Date to be Corrected: August 8, 2016
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: Review of 1 of 4 persons in care's (PIC) care plan determined that a top and bottom bed rail is being used when the PIC is in bed. The PIC can independently give consent for the use of the top and bottom bed rails but there but there is no consent documentation given from a medical practitioner or a nurse practitioner.
Corrective Action(s): Ensure that all restraint agreement is given in writing by both the medical practitioner or nurse practitioner responsible for the health of the person in care.
Date to be Corrected: August 8, 2016
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Review of 1 of 4 person in care's (PIC) care plans found that the oral health care plan was last reviewed by manager January 13, 2015 and last reviewed by hygienist June 23, 2014. Review of documentation determined that the PIC was regularly visiting the dentist and dental care was last provided in May 2016.
Corrective Action(s): Ensure that care plans are reviewed at least once a year to ensure it continues to meet the needs of the person in care who is the subject of the care plan.
Date to be Corrected: August 8, 2016
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