PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: One tub room on the second floor was found with the door open, and no staff present, and water in the tub, as well as chemicals accessible, and personal items were not labelled. of concern is that a person in care could have full access to the room unsupervised, and there is potential for injury.
One staff area/ storage room on the 2nd floor was unlocked, of concern is that there is a ladder to the roof persons in care could access, and the doors open in and if a person in care went into the area they could become trapped.
Corrective Action(s): Ensure all rooms are maintained in a safe condition.
Date to be Corrected:
STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: 1 of 4 staff files reviewed does not have evidence of a completed criminal record check on file.
Corrective Action(s): Ensure all employee files contain evidence of a completed and current criminal record check.
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: 2 of 4 staff files reviewed do not contain any references.
Corrective Action(s): Ensure character references are obtained and on file for all employees hired into a 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: 1 of 4 employee files did not have evidence of qualifications or training.
Corrective Action(s): Ensure the community care facility has copies of diplomas, certificates, or other evidence of the person's training and skills.
Date to be Corrected:
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: 1 of 4 staff files reviewed do not have any evidence of TB screen or immunization status for the employee.
Corrective Action(s): Ensure all staff have evidence that comply with the Province's immunization and TB control programs.
Date to be Corrected:
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: only 1 of 4 employees reviewed had been employed in the care facility for longer than a year. That employees last performance review on file was more than a year old.
Corrective Action(s): Ensure performance reviews for each employee are reviewed regularly and demonstrate the competence required for the duties assigned.
Date to be Corrected:
STAFFING: 32170 - RCR s.42(1)(a) - A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to (a) meet the needs of the persons in care.
Observation: While the day shift today has the full staffing compliment present today, the evening shift has 1 LPN, 1 RN, and only 5 RCAs scheduled. Night shift has 1 RN, and 2 RCAs scheduled, yet there is not a RCA hired to fill the 2nd RCA shift.
In summary, today's staffing compliment is short 3 RCA shifts. There continues to be ongoing staffing issues.
Corrective Action(s): Ensure employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern to meet the needs of persons in care.
Date to be Corrected:
POLICIES AND PROCEDURES: 33240 - RCR s.85(1)(c)(i) - A licensee must do all of the following: (c) make all policies and procedures available (i) to employees at all times.
Observation: Policies accessible to all staff at the care facility was last updated June 2014 as confirmed by management, as not all staff have access to computer login to access on-line policies
Corrective Action(s): Ensure all policies and procedures are accessible to employees at all times.
Date to be Corrected:
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 has ongoing meal tray service, that has not been reassessed in more than 30 days.
Corrective Action(s): Ensure meal tray service is reassessed at least every 30 days, by a medical practitioner, nurse practitioner, or dietitian.
Date to be Corrected:
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 persons in care, it was observed that:
-for 2 persons in care both the TB screen and immunization record was complete
-for 3 persons in care the TB form was complete, however there were no immunization records
-for 1 person in care the TB form was complete, however the immunization record was incomplete and not signed.
Corrective Action(s): Ensure all persons admitted to a 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: Box items are located on the floor in the freezer, not off of the floor. There are also food items in the freezer that have been removed from the original packaging, that are not labelled with the contents or the date opened.
Corrective Action(s): Ensure food is safely stored.
Date to be Corrected:
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