PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation: It was identified that a safe, secure place in which the person in care may store valuable property is not offered to persons in care.
Corrective Action(s): Ensure that persons in care are provided with a safe, secure place in which the person in care may store valuable property.
Date to be Corrected: January 18, 2019
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (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 (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: For one of 4 persons in care auditted, the least restraint agreement was not signed by the medical practitioner.
Corrective Action(s): Ensure that there is a written agreement given by the medical or nurse practitioner, when a restraint is required.
Date to be Corrected: January 18, 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: The admission checklists, MDS observation forms for four of 4 persons in care were not fully completed as is the expectation, as discussed with the manager and one nurse.
Corrective Action(s): Ensure employees implement the policies
Date to be Corrected: January 18, 2019
CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: Review of four care records, discussion with the recreation staff and manager, a recreation care plan has not been created for these four persons, and shared that it has not been completed for any persons in care. Care conferences do not indicate details for recreation, information documented was vague. The Kardex (care plan and guide form) shared information of some interests but not all for two of the 4 persons in care. For one person in care, a recreation assessment was completed in 2017, when the person moved in, no review was reflected in records, and information did not reflect if there was changes or the interests were continuing since admission. For a 2nd person in care, a recreation assessment was completed, but a care plan was not created based on the information within 30 days of admission.
Corrective Action(s): Ensure care plans include a recreation and leisure plan.
Date to be Corrected: January 18, 2019
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: For two of 4 persons in care audited, an update to the diet was not reflected in two of the areas where staff access the most current information for persons in care. It was discussed, there is a discrepency in communication system to ensure that when a change occurs, all areas are updated. The ADL's, Bowel Management and care plan binder, and Kardex did not reflect the changes that had occurred in the Nutrition Care Plan.
Corrective Action(s): Ensure care plans are updated when a substantial change occurs.
Date to be Corrected: January 18, 2019
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: A review of the facility's snack rotation indicated that the snack provided for at least two days for the pureed diet texture did not include two food groups
Corrective Action(s): Please revise the snack rotation to ensure this is implemented.
Date to be Corrected: January 18, 2019
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