PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: The kitchen table, which is made of wood, has its finish worn off exposing the bare wood underneath and of concern is the ability to maintain its cleanliness.
Corrective Action(s): Ensure that all furniture used by persons in care is maintained in a good state of repair.
Date to be Corrected: April 1, 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: During the inspection of the physical facility the following was observed:
- a lower corner cabinet in the kitchen was missing a cupboard door
- a piece of floor molding in the kitchen was masking taped to the wall as it keeps falling off
- a cabinet door in the laundry room was missing a hinge and 2 other cabinets in the laundry room had locks that need to be re-keyed so that they can lock properly (currently, a large plastic child resistant clip is being used to lock these cabinets which store cleaning supplies)
- multiple wall scuff marks and dents were observed in one bedroom along with a missing closet door
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: April 1, 2021
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 the facility's restraint/restriction of rights policy was not implemented by employees when using a restraint to keep a PIC in bed; specifically, although the facility's restraint/restriction of rights policy outlines that:
- alternatives to the use of a restriction have to be explored - the facility could not provide evidence that alternatives were explored.
- the use of a restriction is to be documented in the care plan of the person in care identifying methods and techniques - this was not found to be in the care plan of the person in care.
- the staff administering the restriction must be trained in the use and monitoring of the restriction - the facility could not provide evidence that this has happened.
- the nurse clinician will assess monitoring checklist to determine its efficiency and document its results - the facility could not provide evidence that this has occurred.
Corrective Action(s): Ensure that policies are implemented by employees.
Date to be Corrected: March 18, 2021
CARE AND/OR SUPERVISION: 34470 - RCR s.73(2)(c) - In addition to the requirements under subsection (1), the following conditions apply to the use of a restraint under section 74(1)(b) [when restraints may be used]: (c) the use of the restraint, its type and the duration for which it is used must be documented in the care plan of the person in care.
Observation: It was observed that the facility makes use of a bed with an enclosure that has a zip up flap that is attached to the bed which restricts the movement of a PIC; however, the use of this restraint, its type and the duration for which it is used was not documented in the care plan of the person in care. There was also no evidence of the following before the implementation of this restraint:
- evidence of alternatives being considered before using this restraint [section 73(2)(a) of the Residential Care Regulation]
- evidence of training in the use of this restraint [section 73(2)(b)(i) of the Residential Care Regulation]
Corrective Action(s): Ensure that in addition to the requirement under subsection (1), the following conditions apply to the use of a restraint under section 74(1)(b) [when restraints may be used]: (c) the use of a restraint, its type and duration for which it is used must be documented in the care plan of the person in care.
Date to be Corrected: April 1, 2021
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