PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: Inspection of the medication cabinets found that one of the three cabinets that contain medications, was left unlocked.
Corrective Action(s): Ensure that all medications in the community care facility are safely and securely stored.
Date to be Corrected: July 21, 2016
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: A review 1 of 5 persons in care PRN record, found that 4 of 11 PRN results were not recorded on the PRN record.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: July 21, 2016
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: A review of 1 of 5 persons in care's care plan, determined that the following had not been reviewed within the last year:
-Therapeutic Recreation Services report was dated January 2014 to December 2014
-Leisure/Recreation Outcomes was dated January 2015-December 2015
Corrective Action(s): Ensure that each care plan is reviewed and if necessary, modified 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.
Date to be Corrected: August 8, 2016
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: A review of 1 of 5 persons in care's Medication Administration Record (MAR) found a PRN medication that was listed as "Patient's Own Medication" in MAR. The PRN was from another pharmacy that does not dispense for the facility. The label was faded and hard to read, so it could not be determined if there was an expiration date on the label but it was determined that it had been dispensed in 2013.
Corrective Action(s): Ensure that the dispensing pharmacist packages all medications.
Date to be Corrected: July 21, 2016
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: Review of the menu and nutrition plan documentation determined that the menu had been reviewed by the Registered Dietician (RD); but there were no menu audits or nutritional documentation to ensure that the current menu meets the nutritional needs of the person's in care, based on the Canada Food Guide (CFG).
Corrective Action(s): Ensure that each person in care receives adequate food to meet their personal nutritional needs, based on the Canada's Food Guide and the person in care's nutrition plan.
Date to be Corrected: August 8, 2016
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