LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: An audit of call bell response times has not been completed (this is a repeat contravention from the 2020 routine inspection).
-4 of 6 persons in care reviewed, the following inconsistencies were noted with respect to nutrition and food services:
-food allergies and restrictions documented on the care plan were not listed on a document used by the kitchen to guide dietary staff
-one PIC's food allergy had not been communicated to the kitchen
-Inconsistencies with diet texture and fluid consistency were noted between the nutrition care plan, nursing care plan, dietary profile and kardex.
In discussion with the manager it was determined that a menu audit had not been completed for the current 4 week menu being used. The menu was reviewed but there is no record that the menu meets the audit requirements as outlined in the Audits and More Manual.
It was observed that the menu did not include one food group despite being offered at meals and snacks.
Monitoring of systems are either inconsistent, or not occurring throughout the community care facility, (including: Care and supervision, food and nutrition, medication, as well as staffing) potentially places the health and safety of persons in care at risk.
Corrective Action(s): Please provide a plan on how you will implement a system to ensure that there is consistency between the care plan and documents to support the implementation of care plan. In addition, please provide a plan to licensing regarding a plan for monitoring the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Date to be Corrected: Please provide a plan to licensing by March 26, 2021.
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: One bedroom had damage to the paint and drywall from what appeared to be repeated contact with a wheelchair. This is the same bedroom identified previously, and a repeat contravention from the 2020 routine inspection report.
The BBQ in the courtyard was soiled, both the outside of the BBQ, and inside (grills) with what appeared to be grease and dirt.
In one PICs room there was a sink that did not drain properly, this was discussed with the maintenance manager.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: While the facility's practice is to label and secure personal items for each person in care, on inspection of the tub room observation of unlabeled shampoo and conditioner, as well as an unlabelled basket with an unlabelled comb, and razors were observed; unlabelled nail clippers were on top of the personal items storage container in the shower room. Of concern is the potential risk of cross contamination.
Corrective Action(s): Ensure there is a safe and secure storage area, to secure personal items, including chemical products and hazardous materials.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31850 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation: A weekly menu was not posted in each dining room. The facility currently posts what is being provided for each meal only.
Corrective Action(s): Ensure a weekly menu is posted in a prominent place in each dining area.
Date to be Corrected:
STAFFING: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: On review of 7 staff files, 2 files only had one reference, and 1 file did not have any references.
Corrective Action(s): Ensure 2 or more references are on file for all staff hired into the community care facility.
Date to be Corrected:
STAFFING: 32040 - RCR s.37(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: There was not evidence of a current registration with the BCCN, which would also provide evidence of a current criminal record check for 2 staff files reviewed.
Corrective Action(s): Ensure the manager has obtained any copies of diplomas, certificates, or other evidence of the person's training and skills.
Date to be Corrected:
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 (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: On review of 7 staff files, one staff had not had a performance review since January 2019. In discussion with the manager, the policy for staff performance appraisals requires annual performance reviews.
Corrective Action(s): Please enure the performance of all employees is reviewed regularly to ensure the employee continues to meet the requirements of this regulation.
Date to be Corrected:
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: It was observed that for a three month period - for shift change Narcotic counts, the second nurse's signature was missing at least 10 times, for the time frame reviewed. The medication policy requires double signatures from nurses at shift change. (REPEAT CONTRAVENTION)
Corrective Action(s): Ensure employees comply with the policies and procedure of the medication safety and advisory committee.
Date to be Corrected:
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: Review of emergency plan and discussion with the site determined that there is water on site, however, there is no emergency food supply.
Corrective Action(s): Ensure that there is an emergency plan in place that sets out procedures to prepare for, mitigate, respond to, and to recover from any emergency.
Date to be Corrected:
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: It was noted that throughout the facility in 10-15 rooms, ADL sheets that were posted in PIC rooms, had not been updated to match and reflect the changes made to care plans. For example:
-6 persons in care not at risk for falls and not requiring a fall mat, had one at their bedside. (ADL sheets were removed on day 1 of the inspection).
-For 3 persons in care that require repositioning, there was no evidence to demonstrate that this occurred. No system was in place to record completed tasks.
-There was no process in place to ensure safety checks occurred as required for a PIC.
Corrective Action(s): Ensure that care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34830 - RCR s.83(2) - A licensee of a community care facility with more than 24 persons in care must develop, with the assistance of a dietitian, a nutrition plan for each person in care.
Observation: The site has not had a dietitian in place since June 2020 to develop, review, or revise nutrition care plans. In the absence of a dietitian, the physician and/or nursing staff are overseeing nutritional care plans. Inconsistencies in documentation and care related to nutrition have been noted, please see 30240 - RCR s.61
Corrective Action(s): Please provide a plan to ensure nutrition care plans are being developed and reviewed with the assistance of a dietitian..
Date to be Corrected: March 19, 2021
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: On review of 6 person in care records, it was observed that 4 persons in care did not have a record of immunization on file, and one other person in care did not have an immunization or TB form on file.
Corrective Action(s): Ensure that all persons in care admitted to the community care facility comply with the Province's immunization and TB control program.
Date to be Corrected:
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Observations of the kitchen area include:
-Prepared food on the kitchen counter and fridge was observed to be either uncovered and/or not labelled with a date.
-Food was stored within close range of a sink where chemicals are used. Of concern is the potential for chemical contamination when the sink is used.
Corrective Action(s): Ensure all food is safely prepared, stored, served and handled.
Date to be Corrected:
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: One PICs own supplement, was listed on the MAR, but had a hand written label. On the most recent medication room review provided by the pharmacy (January 2021) the pharmacy noted that all supplements needs to be labeled by the pharmacy. (REPEAT CONTRAVENTION)
Corrective Action(s): Ensure the pharmacist packages all medications.
Date to be Corrected:
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of 6 weight records for the last six months, determined that December 2020 weights for 6 persons were missing. The site is working to implement a system or routine to ensure weights are taken monthly.
Corrective Action(s): Please ensure that each person in care is weighed at least once each month.
Date to be Corrected:
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: On review of 7 staff files:
-2 staff were missing evidence of both immunization history and TB screening
-1 staff was missing evidence of completed TB screening
-2 other staff were missing completed immunization forms.
Corrective Action(s): Ensure the licensee keeps the following records in respect of each employee: compliance with the Province's immunization and TB control program.
Date to be Corrected:
|