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: 1 out of 3 Medication Administration Records (MAR) were reviewed and found that 4 out of 7 PRNs administered were recorded on the back on the MAR, but were not initialled for having given. Also, 1 PRN did not indicate effectiveness. This is a repeat contravention from the previous follow-up inspections (SCLY-AEFUN9).
Corrective Action(s): Ensure that employees comply with all policies and procedures outlined by the medication safety and advisory committee.
Date to be Corrected: December 12, 2016
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: Review of 2 Persons In Care (PIC) care plans showed that they have not be reviewed and/or modified in the past year. They were last reviewed in March 2015. Care plans not being reviewed yearly is a repeat contravention from the previous routine inspection (NTJN-A57QAW).
Corrective Action(s): Ensure that each care plan is reviewed and if necessary modified at least once each year.
Date to be Corrected: December 30, 2016
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Review of the substitution records showed only a substitution from today and licensing was not able to determine if it met the nutritional needs and if it was from the same food group. Discussion with the manager determined that there few substitutions, but they have not been recorded.
Corrective Action(s): Please ensure that substitutions are from the same group and have similar nutritional value.
Date to be Corrected: December 12, 2016
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: Review of the menu audits determined that for the age and gender that the facility appears to be following that it does not meet the nutritional needs of the individuals. For example the audit says they receive 7 grain products each day, but they should be receiving 8.
Corrective Action(s): Please ensure that PIC receive adequate food to meet their personal nutritional needs based on Canada's Food Guide. and their care plan.
Date to be Corrected: December 30, 2016
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: Review of 2 PIC's weight records found the following:
- 1 did not have weights recorded for October and November.
- Another did not have November recorded.
Both records did not indicate the reason for not weighing the PICs.
This is a repeat contravention to the precious follow-up and routine inspection (SCLY-AEFUN9, NTJN-A57QAW).
Corrective Action(s): Ensure that each person is weighed at least once each month.
Date to be Corrected: December 12, 2016
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