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: Upon inspection of the physical facility, it was noted:
1. that the dining room and one PIC’s (Persons in Care) bedroom baseboard heat cover has fallen off exposing the hot heating pipes.
2. One PIC’s bedroom walls have circular patches of discoloured paint and paint chipped/peeled off the wall.
3. One PIC's bedroom windows have significant condensation evident with moisture and water droplets appearing on the
inside of the windows which looks moldy.
4. One PIC’s bedroom window and the kitchen window doesn’t close properly allowing wind drafts to penetrate through
the corners and sides.
The Manager mentioned during inspection that BC Housing had planned to repair/replace the noted items this year but it has not happened until the day of inspection.
Corrective Action(s): Ensure all person's in care (PIC) common areas and PICs’ bedrooms are maintained in a good state of repair. If there is a delay in the repairs/replacement beyond January 2020, the manager is to inform the LO and propose a new date.
Date to be Corrected: January 31st, 2020
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 2 Persons in Care (PICs) files online found that the restraint documents are signed by the Occupational Therapist and family representative.
Corrective Action(s): Ensure that PIC’s with a need for on-going restraint must have the agreement signed by the medical practitioner or nurse practitioner responsible for the health of the person in care.
Date to be Corrected: January 31, 2020
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: Staff did not document fridge and freezer temperature in the log, twice last month and no record was made available to LO for this month.
Corrective Action(s): Please ensure that employees follow and implement the policies and procedures of the facility. Corrected by the time of report presentation.
Date to be Corrected: December 4, 2019
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