STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Review of 8 employee files found the following:
- 1 out of 4 contracted services staff has not had a performance evaluation since 2016.
- 2 out of 4 nursing staff have not had a performance evaluation since 2015.
Corrective Action(s): Please ensure that employees receive regular performance evaluations.
Date to be Corrected: May 29, 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: 1 out of 4 PIC's care plans contained 2 wound assessment and documentation flowsheets which showed the following:
- 1 sheet had 1 out of 7 days where no assessment was documented.
- The 2nd had 8 out of 15 days where no assessment was documented.
Corrective Action(s): Please ensure that employees follow the procedures of the facility.
Date to be Corrected: May 15, 2018
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: 2 out of 4 weight record charts did not have a weight recorded for January 2018.
Corrective Action(s): Please ensure that each PIC is weighed at least once each month.
Date to be Corrected: May 15, 2018
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