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: - Two sets of blinds located in a common area were damaged and could not function as intended.
- The battery for an alarm installed on the pantry door in the kitchen had not been replaced after it stopped working. The alarm is used to alert staff when door is opened by persons in care.
- The cloth and metal straps use to secure the stability rails on either side of a toilet were dirty and rusted. It was explained that the straps are sprayed with bleach which could be attributing to the wear and rust noted.
Corrective Action(s): Please ensure all equipment and furniture is maintained in a good state of repair.
Date to be Corrected: May 26, 2023
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: - The gate at the top of the stairs beside the wheelchair ramp in the garage was found open and unsecured.
- The facility manager reported the stove in the kitchen downstairs was to be unplugged to ensure persons in care safety, however it was found plugged in and able to be turned on at time of inspection. One PIC has unsupervised access to this area of the facility at times.
- A long cord belonging to a outside generator was found left on the floor in the common area downstairs.
- Both the upstairs and downstairs laundry rooms are used and accessed by PICs, however neither have a slip resistant floor surface as required (RCR s. 35(2)(a))
Corrective Action(s): Please ensure all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: May 26, 2023
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: The following observations confirm that the licensee policies regarding medication were not implemented by staff:
- PRN protocols were not developed for all PRN medications for all PICs as required.
- Some PRN protocols were not developed and/or reviewed by a regulated professional as required.
- Some PRN protocols did not include all the required information such as the maximum dose allowed per 24 hours, interval between doses and the reason for the medication.
- Discontinued medication (three) were found stored in the medication area and not returned to pharmacy as required.
- Expired medication (one) was found stored in the medication area and not returned to pharmacy as required.
- Medication safety and advisory meetings and inspections had not occurred in more than 12 months and policy requires every 6 months.
- One over the counter medication was found stored in the medication area and only medication prescribed by a practitioner is permitted to be dispensed by the pharmacy and administered to persons in care.
- Medication Administration Record (MAR) sheet and medication package are to be in agreement so staff can check the "5 rights" with each medication, however MAR records did not all include the route for the medication.
Corrective Action(s): Please ensure staff implement the policies and procedures of the MSAC.
Date to be Corrected: May 26, 2023
POLICIES AND PROCEDURES: 33080 - RCR s.51(2) - A licensee must ensure that the plans described in subsection 51(1) are updated if there is any change in the facility
Observation: A review of the emergency plan and supplies was completed and the following was observed.
- Items had been removed from the emergency food supplies and not replaced resulting in less food being available.
- Supplies were to include a can opener however, none was available.
- Information specific to a person no longer in care remained in the emergency plan.
- Emergency contact numbers had not been updated to reflect the change in pharmacy service provider.
Corrective Action(s): Please ensure emergency plans are updated as required.
Date to be Corrected: May 26, 2023
CARE AND/OR SUPERVISION: 34590 - RCR s.81(2)(b) - A care plan must be developed, to the extent reasonably practical, (b) in a manner that takes into account the unique abilities, physical, social and emotional needs, and cultural and spiritual preferences of the person in care.
Observation: - One person in care (PIC) has specific needs related to their behavior to ensure their own safety and the safety of those around them during a particular activity, however this information was not included in their care plan. The PIC also had been assessed and found to be at risk for falls, however no fall prevention care plan had been developed. The mobility needs of the PIC had also changed over time however their care plan did not reflect these changes.
- One PIC had a history of falls, however did not have a fall risk assessment completed or a fall prevention care plan developed. The PIC had recommendations made by their dental professional during a routine exam, but not all the recommendations were included in the care plan.
Corrective Action(s): Please ensure each PIC has a care plan that is developed to meet their individual needs.
Date to be Corrected: May 26, 2023
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