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: Upon inspection, a medication room cupboard used to store narcotics, also contained stacks of loose papers that were not in a binder and at risk of falling out of the cupboard.
Corrective Action(s): Ensure all areas are maintained in a safe and clean condition.
Date to be Corrected: 22 Mar 2019
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Of four staff files reviewed, one did not have a performance review on file, dating back to 2015.
Corrective Action(s): Ensure that all staff members have their performance reviewed regularly to ensure they demonstrate competence for the duties to which they are assigned.
Date to be Corrected: 01 April 2019
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - 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 (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: One person in care (PIC) was observed to be in bed will all side rails up. Upon inspection of PIC's records there was no agreement for use of restraint found.
Corrective Action(s): Ensure that there is a written agreement by the medical practitioner or the nurse practitioner responsible for the health of the PIC for the use of a restraint. CORRECTED AT THE TIME OF THE INSPECTION
Date to be Corrected: 22 Mar 2019
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: Of four audited PIC's records all were found to be missing documentation indicating compliance with the Province's immunization control program.
Corrective Action(s): Ensure all persons admitted into a community care facility comply with the Province's immunization program.
Date to be Corrected: 01 April 2019
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: Review of the monthly weights found there to be missing weights for numerous PIC's over the past four months.
Corrective Action(s): Ensure all PIC are weighed monthly.
Date to be Corrected: 22 Mar 2019
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