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: Rooms identified to contain potential hazards to persons in care were found unsecured. The doors have the ability to be locked, however were not. This was observed on all but one unit.
This was also identified in Routine Inspection KBEL-BMTU6J.
Corrective Action(s): Please ensure the identified rooms are no longer accessible to any persons in care.
Date to be Corrected: Immediately
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection 74(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 (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: Two restraint agreements providing consent by the person in care's (PIC) representative was incorrectly completed or found to be incomplete for one person in care.
Corrective Action(s): Please ensure there is a written agreement for each restraint used for PICs.
Date to be Corrected: CORRECTED DURING INSPECTION
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: Medication Administration Records (MAR) for one month were reviewed for four persons in care (PIC). The follow up response, assessing the effectiveness of all medications administer as needed (PRN) were not completed as required for two PIC.
Corrective Action(s): Please ensure staff implement facility policies regarding medication administration.
Date to be Corrected: April 8, 2022
CARE AND/OR SUPERVISION: 34370 - RCR s.63(3)(c)(iv) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iv) reassessed by the person in care's medical practitioner, nurse practitioner or dietitian at least once every 30 days.
Observation: One person in care (PIC) receives ongoing room tray services which was approved in writing by their medical practitioner and documented in their care plan, however if was confirmed that there was no system in place to ensure it was reassessed every 30 days as required.
Corrective Action(s): Please ensure that reassessment of ongoing rooms tray service occurs every 30 days as required.
Date to be Corrected: CORRECTED DURING INSPECTION
CARE AND/OR SUPERVISION: 34590 - RCR s.81(2)(b) - A care plan must be developed, to the extent reasonably practical, (b) in a manner that takes into account the unique abilities, physical, social and emotional needs, and cultural and spiritual preferences of the person in care.
Observation: Records were reviewed for four persons in care and it was determined that for three PICs, the information provided in their care plans was either incomplete or inconsistent with the information documented in their most recent assessments and/or other records.
Some items noted were corrected during the inspection.
This was previously identified in Routine Inspection KBEL-CCHN22.
Corrective Action(s): Please ensure that each PIC has a care plan that takes into account the unique abilities, needs and preferences of the PIC
Date to be Corrected: April 8, 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: Records for four persons in care (PIC) were reviewed.
Immunization screening was either incomplete or absent for three of the four PICs.
TB screening was not completed for one of the four PICs.
This was identified in previous routine inspection KBEL-BYSTUC.
Corrective Action(s): Please ensure all PICs comply with the Immunization and TB control program.
Date to be Corrected: CORRECTED DURING INSPECTION
RECORDS AND REPORTING: 39200 - RCR s.78(2)(b) - A licensee must keep, for each person in care, a medication administration record showing (b) the date, amount and time at which the medication was administered.
Observation: Medication Administration Records (MAR) were reviewed for four persons in care and it was noted that for two, not all medications were signed as being administered as ordered.
This was also identified during Routine Inspection KBEL-BMTU6J
Corrective Action(s): Please ensure that the MAR for each PIC records includes the date amount and time at which the medication was administered.
Date to be Corrected: April 8, 2022
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