PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31850 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation: It was observed that the menu for the day was posted, however, it was explained that the weekly menu is required to be posted in a prominant place in the dining area.
Corrective Action(s): Please ensure that the menu for each weekly period is posted in a prominent place in the dining area.
Date to be Corrected: January 17, 2020
CARE AND/OR SUPERVISION: 34670 - RCR s.81(3)(e)(i) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (i) an assessment of the nature of the risk of falling presented by the person in care.
Observation: In review of the care plans for 2 persons in care, it was noted that the fall assessments have not been completed.
Corrective Action(s): Please ensure that the care plan for each person in care includes an assessment of the risk for falls.
Date to be Corrected: January 17, 2020
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: In review of the health care records for persons in care, it was noted that the TB and Immunization Forms for 2 persons in care were not completed.
Corrective Action(s): Please ensure that all persons admitted to the facility have completed TB and Immunization forms as required by the Province's immunization and TB control program.
Date to be Corrected: January 17, 2020
RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: In review of the care plans for persons in care, it was noted that for 1 person in care who has resided in the facility for more than 30 days, a comprehensive care plan had not been developed.
Corrective Action(s): Please ensure that a care plan is developed within 30 days for all persons admitted to the facility.
Date to be Corrected: Janaury 17, 2020
RECORDS AND REPORTING: 39370 - RCR s.84(d) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (d) the duration of the restraint and the monitoring of the person in care during the restraint.
Observation: In review of the health care records for a person in care that has a restraint agreement in place, it was noted that the 'Restraint Agreement Form' and the care plan did not include information regarding the duration of the restraint and the monitoring of the person in care during the restraint. It was also noted that the form titled, 'Written Agreement For The Use of a Restraint' was not completed in full as required by facility policy.
Corrective Action(s): Please ensure that the following information is recorded in the care plan of a person in care when an agreement to a restraint is in place - that the duration of the restraint is documented and there is a plan in place for the monitoring of the person in care during the restraint.
Date to be Corrected: january 17, 2020
RECORDS AND REPORTING: 39670 - RCR s.93 - A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of persons in care, keep the records and personal information of persons in care confidential.
Observation: During the inspection of person's in care rooms, it was noted that the majority of the rooms are shared spaces. The Activities of Daily Living (ADL) Sheets for each person in care are posted on the front of each persons closet door. The Manager explained that the expectation is that these ADL Sheets are faced backwards to ensure privacy and confidentiality for each person's personal care information. It was noted in several rooms that these ADL Sheets were not turned backwards in a manner to ensure privacy.
Corrective Action(s): Please ensure that ADL Sheets in 2 person and 4 person capacity rooms are displayed in a manner to ensure privacy and confidentiality for each person in care.
Date to be Corrected: january 17, 2020
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