PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: The chemical/cleaning supply cupboard was observed to be unlocked. A bottle of bleach was observed under the kitchen sink in a cupboard that did not have a lock. Both areas can be accessed by persons in care.
Corrective Action(s): Ensure cleaning agents, chemicals, and hazardous materials are stored in a safe and secure area.
Date to be Corrected: June 4, 2021
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: Medication Administration Records (MAR) for 2021 were not located in 2 PIC medication binders and a third PIC medication binder did not have MARs for the months of April, May, and June of 2021. The facility medication safety and advisory committee states that MARs are to be included in PIC medication binders in the event that the PICs eMAR cannot be accessed.
Corrective Action(s): Ensure MARs are located in each PIC binder in the event that PIC eMARs cannot be accessed.
Date to be Corrected: June 4, 2021
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: Upon review of the facility's emergency supplies, it was observed that the amount of water in the emergency supply kit was insufficient to support persons in care and staff for a period of 3 days. Additionally, the water packets and food rations in the emergency rations kit had the expiry date of 2016 noted on the packages.
Corrective Action(s): Ensure that emergency supplies are adequate to support persons in care and staff for 3 days and that items are not beyond the expiry date noted.
Date to be Corrected: June 21, 2021
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: Upon review of 2 of 3 PIC finances and financial records, the cash on hand for 1 PIC was less than the amount recorded in the PIC ledger. Additionally, a receipt entered in the ledger was not available to verify one recorded disbursement and a receipt for a second disbursement was available but was not entered into the ledger. Facility policy requires staff to obtain receipts, record disbursements accurately, and ensure PIC ledger and cash on hand balance.
Corrective Action(s): Ensure facility policy in the management of person in care finances and records of disbursements is followed by staff, that an accurate record of disbursements made on behalf of persons in care is maintained, and that receipts are retained and reflect disbursements made.
Date to be Corrected: June 21, 2019
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: Personal hygiene items stored in the upstairs bathroom cupboard could not be identified according to PIC.
Corrective Action(s): Ensure personal hygiene items are stored in a manner that clearly identifies the PIC.
Date to be Corrected: June 21, 2021
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: 1 expired topical medication was stored with current medications.
Corrective Action(s): Ensure expired medications are returned to the pharmacist.
Date to be Corrected: June 21, 2021
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: 3 out of 3 PIC files were reviewed and it was observed that, over the past 12 month period, the weight of 1 PIC was missing for 1 month during 2021 and 2 months since May 2020. Additionally, a reason for the missing weights had not been recorded as per RCR s. 83(5)(a).
Corrective Action(s): Ensure that each person in care is weighed at least once each month and, if a person in care refuses or is unable to be weighed, ensure the reason why the person in care was not weighed is recorded.
Date to be Corrected: June 21, 2021
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