LICENSING: 30050 - RCR s.8(3)(a) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (a) notify a medical health officer.
Observation: It was determined that manager information was not updated.
Corrective Action(s): Ensure notification of manager change occurs are required.
Date to be Corrected: February 5, 2021
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: Rcr 61
It was observed on day one, at one unit, although the meal was served to the person in care, the person in care was not supported to eat for at least 20 minutes. Regular audits were not being completed. It was determined that atleast two disciplines do not have a method of ensuring they are aware of most up to date conditions of persons in care.
Corrective Action(s): Ensure appropriate monitoring of all care and supervision.
Date to be Corrected: March 1, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Audit of water accessible to persons in care, determined temperatures at 6 of 11 sinks determined exceeded 49 degrees celsius.
Corrective Action(s): Ensure water accessible to persons in care does not exceed 49 degrees Celsius.
Date to be Corrected: February 5, 2021
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: Observed were 5 pieces of wooden furniture were in a state of disrepair that would prevent cleaning appropriately. As well, 3 ceiling lifts were observed to have tape across the covers, along with one sling in a state of disrepair that would not be cleanable.
Corrective Action(s): Ensure all furniture and equipment is maintained in a good state of repair.
Date to be Corrected: February 5, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Through out the 3 buildings, multiple areas of walls, some doors, not being maintained in a good state of repair.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: March 1, 2021
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 following areas were determined to not be maintained in a safe and clean condition:
- It was also observed on one unit, a floor area of approximately 3 sq. ft. with cement exposed and, accessible to persons in care and not an area that cannot be cleaned. It was determined that the area has been in this condition for at least a year.
- One clean utility was not in a condition of cleanliness, with clean slings piled on the floor.
Corrective Action(s): Ensure all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: February 5, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31750 - RCR s.35(1)(b) - A licensee must provide the following appropriately furnished and equipped areas: (b) safe and secure locations for medications and the records of persons in care.
Observation: Observations determined one nursing unit gate was left open constantly. As well, during observation of one staff medication administration.
Corrective Action(s): Ensure safe and secure locations for records and medications.
Date to be Corrected: February 2, 2021
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 (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Upon review of staffing systems, it was confirmed that performance reviews for staff have not been completed for at least one year.
Corrective Action(s): Ensure regular performance reviews are completed.
Date to be Corrected: March 1, 2021
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: It was observed that one staff during medication administration orientation did not sanitize hands between resident administration. The medication cart was not locked when the staff left the area to administer medications.
Corrective Action(s): Ensure staff follow the policies of the medication safety and advisory committee.
Date to be Corrected: February 5, 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: The following items were observed as staff not implementing policy:
- One person in care, with an incident which required follow up did not have the proper implementation of policy to ensure safe care and referral for assessment.
- Various documents for admission, on going care, and assessments – determined to not be completed as required. This was consistent with 6 care plans reviewed.
- Multiple IPC prevention measures were not implemented.
- Clean signs for multiple lifts in the hallways, placed where the clean lifts are stored but lacked the signage to confirm. This was also the case for ceiling lifts for 3 of 4 observed.
- The Living at Risk Guideline was not completed for one person in care.
Corrective Action(s): Ensure staff implement policies and procedures.
Date to be Corrected: March 1, 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: 3 care chart reviews confirmed a lack of following the provinces tuberculosis programs, including a lack of a form for one chart and two charts having the forms but not completed.
Corrective Action(s): Ensure all persons in care admitted comply with the province’s tuberculosis programs.
Date to be Corrected: March 1, 2021
RECORDS AND REPORTING: 39290 - RCR s.80(1) - On admitting a person in care to a community care facility, a licensee must ensure that a short term care plan is developed that will guide caregivers in protecting and promoting the health and safety of the person in care.
Observation: It was observed that short term care plans are not documented as fully completed to ensure staff are appropriately guided. This includes documenting if focus care plans are required, if the care plans are reviewed and if the discipline to assess has done so. Although through review of various documentation, there showed some completion of these items, it was difficult to locate and writer had to review many documents to find the relevant documentation. As well, it is determined that short term care plans are not created by recreation.
Corrective Action(s): Ensure short term care plans are created appropriately
Date to be Corrected: March 1, 2021
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