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: Staff complete a personal charting document for each person in care at each shift. In addition, staff complete documentation on an online program. Although there is some duplication of information in both areas, the assistant manager stated they are in the process of completely switching to the online system. Until such time it is expected that staff complete both forms of documentation.
Corrective Action(s): Ensure staff implement the processes in place.
Date to be Corrected: May 11, 2018
RECORDS AND REPORTING: 39580 - RCR s.91(1)(a) - A licensee must ensure that all records referred to in this regulation (a) are current.
Observation: Review of facility systems and records in place, the following areas were identified with information that was not current:
- in the home binder, one page did not state the most recent admission's name as an individual who resided in the home; as well, review of the daily routines, the night shift document included a discharged person in care's name.
- in The Emergency binder, one person in care's (newest admission) consent card was not included; the fire escape plan had a discharged person in care's name stated on it.
- The fire escape plan posted on the wall also stated a discharged person in care's name and not the newest admission's name.
Corrective Action(s): Ensure all records at the facility are current.
Date to be Corrected: May 11, 2018
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