POLICIES AND PROCEDURES: 33020 - RCR s.48(1)(b) - Before admitting a person to a community care facility, a licensee must advise the person, or the person's parent or representative, of (b) the policies of the community care facility respecting expressing concerns, making complaints and resolving disputes under section 60 [dispute resolution].
Observation: In review of the 'new resident information booklet', there was no information provided regarding how a person can make a complaint or resolve a dispute.
Corrective Action(s): Please ensure that persons are provided at the time of admission with a summary of how to express concerns or make a complaint.
Date to be Corrected: January 29, 2022
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: In review of the Medication Administration Records (MAR's), it was observed for 1 person in care that the result/effectiveness for 9 administered PRN's was not documented. As per the Clinical Practice Guideline for Medication Administration, staff are directed to document the client's response to treatment. The PRN Administration Record provides a column for the result/effectiveness to be documented.
Corrective Action(s): Please ensure that policies are implemented by employees re: the documentation of PRN medications.
Date to be Corrected: January 14, 2022
CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (ii) a plan for preventing the person in care from falling.
Observation: In review of a care plan for a person in care, it was noted that this person was assessed at the time of admission as being a 'high falls risk'. An interdisplinary care plan to address the risk of falls was not completed.
Corrective Action(s): Please ensure that a care plan is developed for a person in care who may be prone to falling.
Date to be Corrected: January 14, 2022
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