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 narcotic count sheets for daily shift change had one missing second nurse’s signature in the month of November 2021, and two other narcotic counts had missing second signatures in the month of December 2021.
Corrective Action(s): Ensure employees comply with the policies and procedures of the medication safety and advisory committee. (REPEAT CONTRAVENTION)
Date to be Corrected: January 6, 2022
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation (CORRECTED DURING INSPECTION): A review of the emergency plan and supplies, determined that the emergency water supply available was expired.
Corrective Action(s): Ensure there is an emergency plan in place that sets out procedures for, to mitigate, respond to, and recover from any emergency.
Date to be Corrected: December 9, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: Two of five staff files, did not have completed tuberculosis form documentation. (REPEAT CONTRAVENTION)
Corrective Action(s): Licensee must ensure all staff are in compliance with the Province’s immunization and tuberculosis control program.
Date to be Corrected: January 6, 2022
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: Inspection of the first floor medication room and first floor medication cart, found there was found two unlabelled medications. There was also found two medications were observed with labels from the previous pharmacy. (REPEAT CONTRAVENTION)
Corrective Action(s): Ensure all medications are packaged and labelled by the appointed pharmacy/pharmacist.
Date to be Corrected: January 6, 2022
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