PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Inspection of the downstairs furnace found that one side of the accordion door was missing and broken off. The doorbell located by the interior front door is missing a cover.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: August 3, 2016
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31830 - RCR s.36(2) - If necessary to protect the health or safety of persons in care, a licensee must ensure that the outside activity area is secured by a fence or other means.
Observation: Inspection of the outside fence found that the east-side panels are broken.
Corrective Action(s): Ensure that the outside activity area is secured by a fence or other means.
Date to be Corrected: August 3, 2016
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: (PREVIOUSLY CONTRAVENED ON INSPECTION #KDHL-9XBS5B)
A review of the Medication Administration Record (MAR) found that 9 PRN results were not recorded in 1 persons in care MAR.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: August 3, 2016
POLICIES AND PROCEDURES: 33080 - RCR s.51(2) - A licensee must ensure that the plans described in subsection (1) are updated if there is any change in the facility
Observation: A review of the emergency plan found that it had not been updated since January 2014 and changes have been made at the facility.
Corrective Action(s): Ensure that the emergency plan is current and updated when changes occur.
Date to be Corrected: August 3, 2016
POLICIES AND PROCEDURES: 33410 - RCR s.85(2)(i) - Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: (i) the use of restraints in an emergency.
Observation: A review of the policies and procedures found no policy for the use of emergency restraint. Discussion with the facility manager determined that restraints and emergency restraints are not used at the facility but there is no policy to support this.
Corrective Action(s): Ensure that policies and procedures are complete.
Date to be Corrected: August 3, 2016
CARE AND/OR SUPERVISION: 34120 - RCR s.52(1)(a) - A licensee must ensure that a person in care is not, while under the care or supervision of the licensee, subjected to (a) financial abuse, emotional abuse, physical abuse, sexual abuse or neglect as those terms are defined in section 1 of Schedule D.
Observation: A review of the financial records for one of four persons in care (PIC) found that the PIC's funds were used to purchase the following items:
-a recliner chair
-incontinence pads
-first aid tape
Discussion with the facility determined that the PIC and representative did not direct the facility to purchase these items. The facility manager stated that the PIC was going through more first aid tape and incontinence pads, more than what is supplied by the funding agency, and that the PIC required more of these items. The recliner chair was recommended by the society's Occupational Therapy (OT) as there is a recent decrease in the PIC's mobility and it would provide more comfort for the PIC.
Further review of the petty cash records also found that these items were being purchased by the PIC:
-bedding
-parking at hospital
-a five drawer tower (dresser/furnishing)
A practice directive dated June 15, 2016 states that PIC money will not be used to pay for "parking for medical appointments" or "furnishings for the home" unless there is "written acknowledgement and consent from the trustee or representative". Although the facility manager is aware that the parent representative would be willing to pay for the following items, written consent was not obtained from the PIC's representative.
Corrective Action(s): Ensure that the funds for a person in care is not misused by a person not in care or without the knowledge and full consent of the person in care or his or her parent or representative.
Date to be Corrected: July 1, 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: A review of the menu and menu documentation found that there were no menu audits completed for the current menu.
Corrective Action(s): Ensure the menu and menu planning documentation is complete to 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.
Date to be Corrected: August 3, 2016
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: (PREVIOUSLY CONTRAVENED ON INSPECTION #KDHL-9XBS5B)
A review of the person in care's records found no consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in care of accident or illness.
Corrective Action(s): Ensure that all person in care's records are complete.
Date to be Corrected: August 3, 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: A review of 1 of 4 persons in care's weight record for no weights recorded or reason why weights were not recorded for May or June of 2016. Discussion with facility manager determined that the person in care had refused to be weighed.
Corrective Action(s): Ensure that each person in care is weighed at least once each month or a reason for why the weight was not recorded.
Date to be Corrected: August 3, 2016
|