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: Upon inspection of the tub room, 2 prescription creams were located in the cupboard. Of concern is that this storage practice does not comply with the medication safety and advisory committee (MSAC) policies and procedures.
Corrective Action(s): Ensure that all employees comply with MSAC policies and procedures
Date to be Corrected: 24 Jan 2020
CARE AND/OR SUPERVISION: 34430 - RCR s.73(1)(c) - A licensee must ensure that a restraint is not used unless (c) the safety and physical and emotional dignity of the person in care is monitored throughout the use of the restraint, and assessed after the use of the restraint.
Observation: Of 5 care plans reviewed, 2 were of persons in care whom are using a restraint. Of concern is that neither care plan indicated the frequency of monitoring that is required while the restraint is in use. Additionally there was no documentation found to support that the use of the restraint had been reviewed.
Corrective Action(s): Ensure that the use of a restraint is monitored regularly as prescribed by the care plan and that the use of the restraint is reviewed as indicated in the care plan.
Date to be Corrected: 24 Jan 2020
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: The refrigerator for use by residents, and located on the 3rd floor, did not appear to be cool/cold. The thermometer inside was reading well above the required range of up to 4 degrees C. Facility Management immediately contacted a repair technician who was on site the same day. Food was examined and nothing was considered to be at risk for spoilage.
Corrective Action(s): Ensure that all food is safely stored.
Date to be Corrected: 16 Jan 2020
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