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: An inspection of the physical facility found a hole (approximately 5 to 6 cm in diameter) in the sidewalk on the north side of the facility (which appears to be an old downpipe hole or a clean out hole) which is missing its cap (this is both a potential tripping hazard and a potential entrance for vermin). Additionally, a baseboard heater in the facility's family room was observed to have its end cap (on the east side) separating from the end of the heater.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: February 11, 2022
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: A review of medication administration records for all persons in care found that the effectiveness of a PRN medication for one person in care was not recorded on the person in care's medication administration record (MAR) on two different occasions. Additionally, for two other persons in care, one medication for each was not recorded on the MAR as having been administered.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: January 27, 2022
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: No written agreement was found to be in place for the use of a restraint given by the person in care, the parent or representative of the person in care or the relative who is the closest to and actively involved in the life of the person in care for the use of a wheelchair seat belt restraint (this was the case for all persons in care). Additionally, no written agreement was found to be in place for three out five persons in care for the use of bed side rail restraints. Management relayed that written agreements for the use of restraints for each person in care are in progress and are just awaiting signatures from each person in care's parent, representative, or relative who is closest to and actively involved in the life of the person in care.There was also no evidence of the following before the implementation of the restraints:
- evidence of alternatives being considered before using this restraint [section 73(2)(a) of the Residential Care Regulation]
- evidence of training in the use of this restraint [section 73(2)(b)(i) of the Residential Care Regulation]
Corrective Action(s): Ensure that there is agreement in writing for the use of a restraint given by the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care and ensure that sections 73(2)(a) and 73(2)(b)(i) of the Residential Care Regulation are followed.
Date to be Corrected: February 8, 2022
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: No written agreement was found to be in place for the use of a restraint given by the medical practitioner or nurse practitioner responsible for the health of the person in care for the use of a wheelchair seat belt restraint for five out of five persons in care. Additionally, there was no evidence of the same for three out five persons in care who use bed side rail restraints. Management relayed that written agreements for the use of restraints for each person in care are in progress and are just awaiting signatures from the each person in care's medical practitioner.
Corrective Action(s): Ensure that there is agreement given in writing to the use of a restraint by the medical practitioner or nurse practitioner responsible for the health of the person in care.
Date to be Corrected: February 8, 2022
CARE AND/OR SUPERVISION: 34700 - RCR s.81(3)(f)(i) - A care plan must include all of the following: (f) if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan (i) to prevent the person in care from leaving.
Observation: A review of all care plans for persons in care found one person in care to be identified as at risk of wandering; however, no plan was observed to be in place to mitigate this risk.
Corrective Action(s): Ensure that, for persons in care who are identified as being at risk of leaving the community care facility without notification of an employee, a plan is in place to prevent the person in care from leaving.
Date to be Corrected: February 4, 2022
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: A review of care records found that one out of three person in care records reviewed did not have evidence of written consent from the person in care or a parent of representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Corrective Action(s): Ensure that written consent is kept with each person in care's record 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 case of accident or illness.
Date to be Corrected: February 11, 2022
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: A review of menus found that the current menu did not have evidence of a menu audit having been completed.
Corrective Action(s): Ensure that a record is kept of the results of monitoring of food services and nutrition care.
Date to be Corrected: February 4, 2022
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