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 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Three staff were without performance reviews. Five staff were overdue to have performance reviews.
(This is a repeat contravention documented in Routine Inspection Report KDHL-BYT7DH dated March 2, 2021).
Corrective Action(s): Ensure regular reviews of employee performance to ensure competence.
Date to be Corrected: March 21, 2022
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 one month there were greater than 50 instances where the effects of PRN medications were not documented in the Medication Administration Record. This is required as per the policies set by the Medication Safety and Advisory Committee.
Corrective Action(s): Ensure policies and procedures are implemented by employees
Date to be Corrected: January 28, 2022
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: Care Plans for two Persons in Care were not updated after they experienced changes related to falls.
Corrective Action(s): Please ensure care plans are reviewed and modified.
Date to be Corrected: March 4, 2022
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: For two Persons in Care it could not be determined if their care plans were being followed. Inconsistent information was in the PICs’ care plans (This is a repeat contravention documented in Routine Inspection Report KDHL-BYT7DH dated March 2, 2021).
Corrective Action(s): Ensure the PIC’s care plans are implemented.
Date to be Corrected: March 4, 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: Documentation for tuberculosis and immunization was missing or incomplete for three Persons in Care. (This is a repeat contravention documented in Routine Inspection Report KDHL-BYT7DH dated March 2, 2021).
Corrective Action(s): Ensure PICs complete with the Provincial immunization and tuberculosis program
Date to be Corrected: March 31, 2022
MEDICATION: 36160 - RCR s.72(a) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (a) the person in care is no longer taking the medication.
Observation: A discontinued narcotic medication remained stored with a PIC’s required medication.
Corrective Action(s): Ensure medications are returned to the pharmacy if no longer required.
Date to be Corrected: January 19, 2022
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: More than 10 PIC records did not include written consent to call a medical/nurse practitioner or ambulance in the event of an accident or injury for the Persons in Care.
Corrective Action(s): Ensure PIC records are complete.
Date to be Corrected: March 31, 2022
RECORDS AND REPORTING: 39430 - RCR s.86(c) - A licensee must keep the following records in respect of each employee: (c) compliance with the Province's immunization and tuberculosis control programs.
Observation: Three employee files did not include record of compliance with the Province’s immunization and tuberculosis program.
Corrective Action(s): Ensure records are kept of each employee’s compliance with the Province’s immunization and tuberculosis program.
Date to be Corrected: March 31, 2022
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