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: It was observed, during the inspection of the medication room, that there was a pill in a blister pack with the name of the medication torn off the packaging. This pill was in a bag with other pills located in a person in care's medication tray.
Corrective Action(s): Ensure all medications are safely and securely stored. This pill was discarded at the time of the inspection.
Date to be Corrected: 22 Mar 2019
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 there was missing documentation to indicate the effectiveness of PRN medications that had been administered. This documentation was missing for all three of the PRN medications reviewed.
Corrective Action(s): Ensure that all staff comply with the policies and procedures of the medication and safety advisory committee.
Date to be Corrected: 22 Mar 2019
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: It was observed that there was incomplete documentation on the staff worksheet that indicating that safety checks were not completed. There were also missing times and dates that were not completed on the Dementia Observation Sheet required for one person in care.
Corrective Action(s): Ensure that policies are implemented by employees.
Date to be Corrected: 22 Mar 2019.
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: Of four randomly selected Activity of Daily Living sheets reviewed, one indicated the person in care (PIC) was receiving ongoing room tray service. Follow-up with this PIC's care plan did not include an reassessment of this practice at least once every 30 days as required.
Corrective Action(s): Ensure all PIC's receiving ongoing room tray service are reassessed at least once every 30 days by a medical practitioner, nurse practitioner or dietician.
Date to be Corrected: 22 Mar 2019
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: Of four care plans randomly selected for review, three were found to have sections that had not been reviewed or revised in over a year.
Corrective Action(s): Ensure care plans are modified as necessary and reviewed at least annually to ensure they meet the needs and preferences of persons in care. The facility staff have identified these concerns with care plans and have recently developed a system of self-monitoring and effective documenting that will assist with maintaining compliance moving forward.
Date to be Corrected: 29 Mar 2019
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: Of four person in care records reviewed, three did not include immunization documentation to indicate compliance with the Province's immunization and tuberculosis control programs.
Corrective Action(s): Ensure all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: 22 Mar 2019
RECORDS AND REPORTING: 39630 - RCR s.91(3) - A licensee must ensure that a record relating to a person in care is accessible only to employees who require access to perform their duties in relation to the person in care.
Observation: Inspection of the dining room area found there to be records relating to a person in care stored in cupboards that are potentially accessible to all people visiting this facility.
Corrective Action(s): Ensure that all person in care records are accessible only to employees who require access to perform their duties.
Date to be Corrected: 22 Mar 2019
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