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: Review of the medication safety and advisory committee policies and procedures, policy is not currently being followed in the following areas:
- Annual Medication Safety and Advisory Committee meeting is not occuring.
- PRN documentation is not being followed to state that the medication is effective or not. For two persons in care, PRN results were missing, and for one the two persons, at least half of 15 results were not documented.
- At present monitoring of medication errors are not being analyzed by the Medication Safety and Advisory Committee.
- The Medication Safety and Advisory committee does not have all staff member who attend sign the meeting minutes.
- The Medication Safety Committee does not review policies.
Corrective Action(s): Ensure the policies and procedures of the medication safety and advisory committee are implemented.
Date to be Corrected: April 1, 2018
POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: Review of medication administration system, medication policies and discussion with the manager and nurse clinician - when administration of PRN medication occurs, staff are occasionally unable to document effectiveness of medication as their shift ends. Of concern is there lacks direction for staff on timelines of monitoring and documenting PRN results.
Corrective Action(s): Ensure there is written policy to guide staff in all matters relating to the care and supervision of persons in care.
Date to be Corrected: April 13, 2018
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Medication Policies do not have evidence of being reviewed. Licensing audit included review of policies, meeting minutes, discussion with the manager and the Registered Nurse Clinician.
Review of the Licensing requirements/ policies, TB guidelines for staff (1997) were in place.
Corrective Action(s): Ensure policies are reviewed at least once a year, if no revisions are required.
Date to be Corrected: April 13, 2018
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: Staff are to sign sheets in each person in care's binder that they have read and understood what is in each care plan. There lacks a signature by staff when there is an update to the care plan as required.
Corrective Action(s): Ensure staff implement policies and protocols that are in place.
Date to be Corrected:
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: In an audit of dry/ canned goods - 1 can identified as expired from June 2017. It appears to not be on the food list for the facility. The manager states it may be a staff members.
Corrective Action(s): Ensure all food is safely stored.
Date to be Corrected: April 13, 2018
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