PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31250 - RCR s.21(b) - A licensee must ensure that all furniture and equipment for use by persons in care (b) are compatible with the health, safety and dignity of the persons in care.
Observation: Review of the tub rooms found that one tub was broken an not in use. Discussion with the staff determined that maintenance was aware and staff are using another rub room on the other side of the floor and have access to two shower rooms.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: July 15, 2020
STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: Review of employee files and discussion with the GM determined that approximatedly 25% of employees reviews were still outstanding.
Corrective Action(s): Ensure that the performance of each employee is regularily reviewed.
Date to be Corrected: July 15, 2020
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: According the facilities MSAC's policies and procedures, narcotic counts are to be completed at the start of each shift (3 times per day). On two days in June 2020, these counts were only completed twice per day.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: July 15, 2020
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: Review of the documentation that captures missed baths found that staff had not completed the forms as required by facility leadership and further documentation had to be reviewed to ensure if baths were received.
Corrective Action(s): Ensure that documentation polices are implemented by employees.
Date to be Corrected: July 15, 2020
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: Review of the care plans documentation contained in the chart, family binder, ADL's and computers found that information contained was inconsistent.
Corrective Action(s): Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Date to be Corrected: July 15, 2020
CARE AND/OR SUPERVISION: 34890 - RCR s.83(4)(b) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (b) immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Observation: Review of 6 persons in care's weights found a significant change in the weight. Documentation reviewed could not determine if staff immediately sought the advice of a health care provider.
Corrective Action(s): Ensure that the advice of the health care provider is immediately sought if there is a significant change in weights.
Date to be Corrected: July 15, 2020
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Review of two floor tub and shower rooms found personal hygiene products (ex. razors, combs, shampoo) that did not have any identifiers for which person in care they belonged too.
Corrective Action(s): Ensure that there is a program in place to ensure that persons in care are utilizing their own designated personal hygiene products.
Date to be Corrected: July 15, 2020
ADDITIONAL CCALA SECTIONS: 50050 - CCALA s.7(1)(b)(i) - A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care.
Observation: Review of one person's in care bath record found that the PIC had missed their weekly bath for 4 weeks. Discussion with staff state that bed baths are given when tub baths are missed. Review of documentation could not confirm if the missed bath's were given at a later date or if there were bed baths to replace them.
Corrective Action(s): Ensure that the care required for persons in care promotes the health, safety, and dignity of the persons in care.
Date to be Corrected: Immediately
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