PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Found within a person in care's bathroom was a razor on the bathroom counter. In one of two tub rooms, there was a basket on the shelf containing an electric shaver, and an electric nose hair trimmer all with no labels to identify who the items belong to.
Corrective Action(s): Ensure all hazardous materials are stored in safe and secure areas, not accessible to persons in care.
Date to be Corrected: March 18, 2022
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: A selection of completed performance evaluations was not able to be provided by the facility for any staff who are employed by the facility. The most recent performance evaluations were done in 2017.
Corrective Action(s): Ensure all staff performance is reviewed on a regular basis to ensure they continue to meet the requirements of this regulation
Date to be Corrected: March 18, 2022
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: The facility staff informed they require all nurses to have first aid certification, but there was no evidence able to be provided the required certification was current for the staff.
Corrective Action(s): Ensure persons in care have access to an employee who holds a valid first aid certificate at all times.
Date to be Corrected: March 18, 2022
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: -In two medication rooms, there were two food items found that were identified to not be from the facility stock. Also found was one staff cup within one medication room. (This was corrected during inspection)
-Four person in care's med administration records were reviewed, and two person in care's PRN records did not show evidence of a follow up evaluation for medications administered four times over a two month period. A follow up to administration is a requirement per facility policy.
-Review of the narcotic count documentation in two medication rooms showed two instances of a second staff signature not included for a narcotic count, as per facility policy
-In one of two medication rooms on the narcotics record for a period of one month, there were seven instances where two staff signatures were present for a medication administered. For the same medication, there was no dosage administered indicated or waste dosage recorded, which are both required, per facility policy.
Corrective Action(s): Ensure all employees comply with medication safety and advisory committee policies.
Date to be Corrected: March 18, 2022
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: Four person in care's charts were reviewed and found the information for behavior related assessments was not consistent in all areas information was provided for one person in care's plan.
Corrective Action(s): Ensure all person in care's care plans are consistent wherever care plans information is written.
Date to be Corrected: March 18, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Three serveries were reviewed and in one servery there were a pair of shoes in the bottom of one cupboard, two staff cups and five food items incorrectly labelled in the freezer.
Corrective Action(s): Ensure all food areas are kept clean of non-food items, staff personal items and food is packaged appropriately for the persons in care.
Date to be Corrected: March 18, 2022
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: Two medication carts were reviewed, and found within one cart was one person in care's own supplied medication, that did not have a pharmacy label attached, and the medication was reported by staff to not be supplied or packaged by the pharmacy, but the medication was on the Medication Administration Record.
Corrective Action(s): Ensure all medications are packaged by the designated pharmacist.
Date to be Corrected: March 18, 2022
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Documentation for the facility that tracks monthly weights was reviewed for three wings, and found within a three month period, there were five instances of no weight or reason was documented.
Corrective Action(s): Ensure all persons in care are weighed at least once per month, or a documented reason is provided as evidence for not having weighed the person in care.
Date to be Corrected: March 18, 2022
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