PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: Review of 2 person in care (PIC) rooms, foam mats (used for falls) on the ground did not have any protective coverings on them, making them uncleanable and a concern for sanitation, in addition ,to being positioned on the floor where staff would need to step on them to provide care or access parts of the room or closet.
Corrective Action(s): Ensure all furniture and equipment for use by persons in care are maintained in a safe and clean condition.
Date to be Corrected: March 16, 2018
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: 3 staff audits completed, 1 lacked performance review within the time frame per policy. In addition, for a staff person whose main line is in another program (facility), the manager for this facility did not participate in the performance review that was completed. The concern is that there is no evidence of review to ensure that the employee continues to meet the requirements of this regulation at this site.
Corrective Action(s): Ensure performance reviews are completed regularly to ensure that the employee continues to meet the requirements of this regulation.
Date to be Corrected: March 16, 2018
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: Review of 2 person in care records. 4 PRN results were not completed as required per policy. In addition, 2 medications did not have the discharged (dc) scribed as required when a new medication order is received and a new medication administration record is initiated.
Corrective Action(s): Ensure all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: March 16, 2018
CARE AND/OR SUPERVISION: 34640 - RCR s.81(3)(c)(i) - A care plan must include all of the following: (c) a nutrition plan that (i) assesses a person in care's nutrition status.
Observation: In review of person in care records and discussion with the manager, it was stated that menu satisfaction surveys have not been competed for persons in care.
Corrective Action(s): Discussion with manager that satisfaction surveys can be completed and adapted as per person in care communication to meet the intent of regulation. Ensure nutrition forms are completed to assist in assessing a person in care's nutrition status, including preferences.
Date to be Corrected: March 16, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Inspection of facility fridge, observation of one broken fridge drawer making it difficult to clean and potential for cuts as plastic handle is broken and sharp. In addition, a food spill was noted in the second fridge drawer. The manager stated there is an expectation to clean spills as they occur.
Corrective Action(s): Ensure all food is safely prepared, stored, served and handled.
Date to be Corrected: March 16, 2018
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: In one staff file, an incident involving a person in care was noted from June 2017. CCFL was not notified of the incident in the manner required by the Medical Health Officer.
Corrective Action(s): When a person in care is involved in a reportable incident, ensure CCFL is immediately notified in the form and in the manner required by the medical health officer.
Date to be Corrected: March 16, 2018
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: For one person in care, weights have not been documented from June 2017 to Dec 2018. Manager could not confirm the reason for lack of documentation.
Corrective Action(s): Ensure that each person in care is weighed at least once a month with documentation to confirm in place.
Date to be Corrected: March 16, 2018
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