Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-BZ7LTL
FACILITY NAME
Bradley Centre		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962MVC
FACILITY ADDRESS
45600 Menholm Rd		FACILITY PHONE
(604) 795-4103
CITY
Chilliwack		POSTAL CODE
V2P 1P7		MANAGER
Kim Norman
INSPECTION DATE
March 05, 2021		ADDITIONAL INSP. DATE (multi-day)
March 12, 2021		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
01:00 PM		DEPARTURE
03:30 PM		ARRIVAL
10:00 AM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection.
The following areas were reviewed:
Licensing
Physical Facility
Staffing
Polices & Procedures
Care & Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records and Reporting

As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.
Visit the CCFL website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo for:

· Additional resources and
· Links to the Legislation (CCALA & RCR)
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
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 following was observed:
1). Review of the PICs MAR found 3 staff signatures missing for medications administered and no record of effectiveness documented for 6 PRN medications administered.
2). A review of 6 PIC files found that 1 PIC had missing insulin dosage on March 1, 2021.

Corrective Action(s): Ensure that employees comply with all policies and procedures related to medication administration and documentation.

Date to be Corrected:

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: Inspection of the tub room found 4 large shampoo and conditioner in a basket on a table adjacent to the tub. Discussion with the nurse incharge noted the process in place is for staff to dispense the required amount of shampoo from the storage cupboard into cups for each PIC during bath assist.

Corrective Action(s): Ensure that staff follow and implement the policy and procedures of the facility.

Date to be Corrected:

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: A review of the wound care records of 3 PICs found:

1). 1 PIC's file had inconsistency with the frequency of the wound treatment plan being implemented.
2). 1 PIC's file had no wound flow sheet to document the follow up of the treatment plan.

Corrective Action(s): Please ensure that care and supervision are consistent and care plans are followed with evidence of proper documentation and that the action plan created is implemented and completed.

Date to be Corrected:

RECORDS AND REPORTING: 39370 - RCR s.84(d) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (d) the duration of the restraint and the monitoring of the person in care during the restraint.
Observation: Review of 3 PICs on restraint use noted that no hourly monitoring was documented for 5 days for 1 PIC. 2 PICs restraint monitoring document was also not completed by nurses twice for 2 days in March.

Corrective Action(s): Please ensure appropriate documented records are in place for PICs on restraint use.

Date to be Corrected:


Comments

Please note: This report was written off-site due to the Covid-19 visitor restrictions in place, and forwarded to the Licensee. Thank you to all the staff for their assistance with this inspection.

Should any further clarification or questions arise regarding this report, please contact your Licensing Officer.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Mar 26, 2021
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.