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: Two topical medication storage drawers were unlocked.
Corrective Action(s): Ensure the safe and secure storage of all medications.
Date to be Corrected: Corrected at time of inspection
STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: The facility policy indicated that fire drills are to be completed once a month. Upon review of fire drill records for 2021, drills were observed to have not been conducted for February, April, and June.
Corrective Action(s): Ensure all employees are trained in the implementation of emergency response plans and that fire drills are conducted monthly, as per facility policy.
Date to be Corrected: July 23, 2021
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - 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 (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: (REPEAT CONTRAVENTION) Restraints are in use for all persons in care for safety purposes: however, signed consents have not been obtained from the parents/representatives and medical practitioner for all restraints. Additionally, agreement to the use of restraints, including the type or nature of restraint and the frequency of reassessment, have not been included in PIC care plans as required as per RCR s.81(3)(1)(iii).
Corrective Action(s): Ensure signed consents for the use of restraints are obtained from the parent or representative of persons in care, the medical practitioner or nurse practitioner, and that agreements to the use of restraints, including the type or nature of restraint and the frequency of reassessment, are included in PIC care plans.
Date to be Corrected: July 23, 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: (REPEAT CONTRAVENTION) Upon review of the MAR binder for 6 PIC's, the following was observed:
- Documentation of PRN administration and effects was missing 5 times for 1 PIC
- Documentation of PRN administration was missing 6 times for a second PIC, 2 times for a third PIC; and 3 times for a fourth PIC
- Documentation of PRN effects was missing 4 times for a fifth PIC
Corrective Action(s): Ensure all PRN medication administration and effects are documented in the nurses notes.
Date to be Corrected: July 9, 2021
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: 2 of 3 PIC files reviewed did not include a record of immunization or compliance with the Province's tuberculosis control program.
Corrective Action(s): Ensure person in care records include a record of immunization and compliance with the Province's tuberculosis control program.
Date to be Corrected: July 23, 2021
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Two expired medications and one discontinued medication were stored with current medications.
Corrective Action(s): Ensure expired and discontinued medications are returned to the pharmacy.
Date to be Corrected: Corrected at time of inspection
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: Upon review of facility menus and menu audits, the following was observed:
- rotating menus did not include 2 nutritious snacks with 2 food groups per snack
- menu audit counts did not appear to accurately reflect all food group amounts on the menus
- menus did not appear to meet daily minimum grain serving requirements as per Canada's Food Guide
Corrective Action(s): Ensure each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide
and the person in care's nutrition plan. It is suggested that serving sizes be included on the menus as a means of demonstrating accuracy of the menu audits.
Date to be Corrected: July 23, 2021
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (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: 3 out of 6 PIC files were reviewed and it was observed that the weight of 1 PIC had not been recorded for June 2021, the reason for which was not recorded in the PIC's nutrition plan or weight record.
Corrective Action(s): Ensure each person in care is weighed at least once per month and that reasons for not weighing a PIC are documented in the nutrition plan and weight record.
Date to be Corrected: July 9, 2021
RECORDS AND REPORTING: 39620 - RCR s.91(2)(c) - In respect of a record referred to in this regulation, a licensee must (c) produce records, on demand, to the medical health officer.
Observation: Upon review of records for 1 person in care, staff stated they had the following records, but were unable to produce the same at the time of inspection:
- height and weight recorded on admission
- list of allergies
- emergency information and identification to describe and identify the person in care
Corrective Action(s): Ensure records are maintained and stored in a manner so that they can be produced, on demand, to the medical health officer.
Date to be Corrected: July 9, 2021
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