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 Catalyst medication system noted that in 2 out of 2 instances the medication was administered at a later time than scheduled or refused and no documentation was completed.
Corrective Action(s): ensure all documentation related to medication administration is completed as per the MSAC policies and procedures
Date to be Corrected: May 30, 2019
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 the ADL's posted in 6 rooms showed that although the care plans had been updated in the person in cares chart it had not been updated on the room ADL's
Corrective Action(s): Ensure care plans are reviewed and updated on all documentation used to support PIC's
Date to be Corrected: May 30 ,2019
CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Observation: Review of the monthly weight charting showed that in the month of April 6 weights were not documented. Through discussion with the DOC it was explained that the scale had been damaged and weights were not able to be done.
Corrective Action(s): Ensure that the reason for weights not being completed is documented
Date to be Corrected: May 30, 2019
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: Review of 4 PIC's files showed that 1 out of 4 was missing the immunization record form and 3 of 4 were missing some of the immunization record information
Corrective Action(s): ensure all persons comply with the immunization control programs
Date to be Corrected: May 30, 2019
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: During inspection it was noted that the fridge and freezer in the servery did not have temperature documentation. through discussion with staff and manager it was determined that the sensor is damaged and staff had not been taking manual temperature readings
Corrective Action(s): ensure fridge and freezer temperatures are taken daily and documented
Date to be Corrected: May 23, 2019
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