LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: For Weatherby 2:
- The first HCA Flow Sheet right after the bowel movement document has no month, but it can be assumed it is for September 2023. One initial for evenings is not documented. Also the section where staff are to initial for the section around "care provided as per care plan/ADLs" not documented in two areas.
For Dr. Al Hogg Pavilion:
- The HCA Flow Sheet for example for two dates (1 for days and 1 for evenings) with no staff initials noted back in July 2023. In addition, there are 2 pages to the HCA Flow Sheet right after the bowel movement documented (September 2023 noted on the bowel movement document), however no date including month on the HCA Flow Sheet.
- The HCA Flow Sheet for example for two dates in October 2023 for nights under the section "initial care given as per ADL/Care Plan".
- 3 post fall management documentation not completed in full. For example, (1) time the Medical Practitioner and Family/Representative was notified for 1 incident, (2) time and date the ambulance was notified for the 2nd and 3rd incidents.
- An advanced are planning document was not completed and the Residential Care Coordinator was going to follow-up on this.
Corrective Action(s): Please ensure the care and services are regulary monitored to ensure the requirements of the Community Care & Assisted Living Act and Residential Care Regulation are being met.
Date to be Corrected: November 15, 2023.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: In Dr. Al Hogg Pavilion, a random review of the hot water temperatures at the ensuite washroom sinks indicated the following three readings:
* 53.9 degrees Celsius (last reading) and slowly increasing.
* 54 degrees Celsius (last reading) and slowly increasing.
* 51 degrees Celsius (last reading) and slowly increasing.
Corrective Action(s): Please ensure water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: October 26, 2023.
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(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: A weight for one month was not documented for a person in care in Weatherby 2.
Corrective Action(s): Please ensure persons in care are weighed on a monthly basis and if there is a reason a weight can't be taken (e.g., scale is not working, refusal by the person in care, etc), please document accordingly.
Date to be Corrected: October 31, 2023.
|