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 4 MARs for May 2018 found the following:
- 1 PIC's MAR had 2 signatures not present.
- Another PIC's MAR has 5 signatures not present.
Corrective Action(s): Please ensure that employees comply with all policies and procedures related to medication administration and documentation.
Date to be Corrected: May 25, 2018
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: 2 out of 4 wound care flow sheets reviewed found that wounds are not being checked, provided care to, and initialed as having done so, for the frequency the care plan outlines.
- 1 person in care's (PIC) flow sheet indicated that it was to be checked and the dressing changed every 3 days and there were 2 occasions of there being 4 and 5 days between changing as there were no signatures indicating it was done.
- Another PIC's flow sheet did not indicated how often the dressing needs to be changed or checked and had an occurrence where it was not checked for 2 days. This PIC also has another wound that was being checked each day accept for 4 days where there were no signatures.
Corrective Action(s): Please ensure that employees follow the facilities policies and procedures for providing and documenting wound care.
Date to be Corrected: May 25, 2018
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: 1 out of 4 PIC's RAI care plans that were reviewed found the following:
- The PIC's recreation care plan has not been reviewed or updated since October 2015 and their nutrition care plan has not been reviewed since May 2015.
Corrective Action(s): Please ensure that care plans are reviewed at least once each year.
Date to be Corrected: June 8, 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: The freezer in the dining room, which is also used by PICs, contained 2 food items that were not labelled and were not in their original packaging to show what it was and when it expires.
Corrective Action(s): Please ensure that food is stored in a safe manner.
Date to be Corrected: May 25, 2018
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation (CORRECTED DURING INSPECTION): 1 PIC had an over-the-counter medication in their room. Staff removed it once pointed out.
Corrective Action(s): Please ensure that all medications are packaged by the pharmacist.
Date to be Corrected: May 25, 2018
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