PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31250 - RCR s.21(b) - A licensee must ensure that all furniture and equipment for use by persons in care (b) are compatible with the health, safety and dignity of the persons in care.
Observation: The following health concerns were identified throughout the neighborhoods:
- Care Aid carts, that store personal care cleaning products and creams, incontinence pads, gloves, and wipes are being stored in alcoves in the hallways. The carts are left unattended.
- Incontinence pads, wipes, and gloves are being stored in the hand rails.
Corrective Action(s): Please ensure that all equipment and items intended for care is compatible with the health, safety, and dignity of PIC.
Date to be Corrected: March 29, 2018
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: The following bedrooms were found to be in need of repair:
- One PIC's bedroom sink was sticking out, about half of an inch, from the wall and was not secured.
- Another PIC's bedroom has 2 round holes in the wall that go through the drywall. The room also has chipped paint, down to the metal, on another wall.
Corrective Action(s): Please ensure that all bedrooms are maintained in a good state of repair.
Date to be Corrected: April 20, 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: Discussion with the manager determined that employee appraisals have not been conducted recently, and potentially have not been conducted since 2014.
There is a plan in place to conduct the appraisals this year.
Corrective Action(s): Please ensure that employee appraisals are conducted regularly.
Date to be Corrected: April 20, 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: The following issues have been identified as staff not complying with policies and procedures:
- 1 PIC's 7 day assessment was not filled in for 2 days
- Weekly nurses audits have either not been completed in the past several months or have areas that have not been checked.
The following care issues were identified in PICs' care plans and not recorded on the kardex:
- 1 PIC who is at risk of wandering
- 2 PIC who is at risk of falls
Corrective Action(s): Please ensure that employees implement and follow policies and procedures.
Date to be Corrected: April 20, 2018
CARE AND/OR SUPERVISION: 34440 - RCR s.73(2)(a) - In addition to the requirements under subsection (1), the following conditions apply to the use of a restraint under section 74(1)(b) [when restraints may be used]: (a) all alternatives to the use of the restraint must have been considered and either implemented or rejected.
Observation: 2 out of 6 PIC's care plans that were reviewed had identified restraints. Both PIC's care plans did not identify if any alternatives had been considered before implementing the restraint. One of the PIC's forms had a place for alternatives to be recorded and was blank. The other PIC's form did not have a place to record alternatives.
Corrective Action(s): Please ensure that alternatives are at least considered and documented before implementing a restraint.
Date to be Corrected: April 20, 2018
CARE AND/OR SUPERVISION: 34620 - RCR s.81(3)(a)(iii) - A care plan must include all of the following: (a) a plan to address (iii) if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment.
Observation: 1 PIC's care plan has the use of a restraint circled on a general information form (with no date), but there is no care plan with further information regrading the restraint.
Corrective Action(s): Please ensure that a care plan is developed for the use of restraints before being implemented.
Date to be Corrected: April 20, 2018
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: 6 care plans were reviewed and found that the following care plans have not been reviewed in the past year:
- 1 PIC who has a restraint care plan has not been reviewed since 2016.
- Another PIC who also have a restraint documented has not date on it.
- Another PIC's dental care plan has not been reviewed since 2012.
Corrective Action(s): Please ensure that care plans are reviewed at least once each year.
Date to be Corrected: April 20, 2018
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 health and hygiene concerns were found:
- One 4 PIC room, with 1 shared bathroom, had toothbrushes, toothpaste, and a hair brush that were not labelled and were left on the counter.
- One tub room had deodorant and 2 shaving creams left on the counter that were not labelled.
Corrective Action(s): Please ensure that there is a program to assist and instruct PICs in maintaining and storing personal care items.
Date to be Corrected: April 20, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: The following food storage issues were identified:
- One PIC's bathroom had boost, cans of pop, and other food items stored in it on a shelf beside the toilet.
- 3 freezers is the resident dining rooms has muffins that were individually wrapped with no label.
- 1 freezer had frozen cut-up fruit in it that did not have a label.
Corrective Action(s): Please ensure that food is safely stored.
Date to be Corrected: March 29, 2018
RECORDS AND REPORTING: 39610 - RCR s.91(2)(b) - In respect of a record referred to in this regulation, a licensee must (b) keep a record other than one referred to in paragraph (a) in a place from which it can be retrieved within a reasonable time, on request.
Observation: Discussion with maintenance determined that fire drills are being conducted each month, but that records of this are not stored at the facility.
Corrective Action(s): Please ensure that a copy fire drills records is available at the facility for review.
Date to be Corrected: April 20, 2018
RECORDS AND REPORTING: 39630 - RCR s.91(3) - A licensee must ensure that a record relating to a person in care is accessible only to employees who require access to perform their duties in relation to the person in care.
Observation: There was a binder with PICs' information being stored in one of the dining rooms in the hand rail. This area is not always monitored by staff and PIC and visitors would have access to this binder.
Corrective Action(s): Please ensure that PICs' information is stored in a manner that prevents unauthorized access.
Date to be Corrected: March 29, 2018
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