PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31250 - RCR s.21(b) - A licensee must ensure that all furniture and equipment for use by persons in care (b) are compatible with the health, safety and dignity of the persons in care.
Observation: For 1 person in care, to ensure the person does not fall out of bed, the person’s commode chair and wheelchair is backed in at the lower half of each side the bed.
Corrective Action(s): Ensure that all furniture and equipment for use by persons in care are compatible with the health, safety and dignity of the persons in care.
Date to be Corrected: May 31, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: 1 cabinet in a bathroom, 1 in the dining room and 1 in the kitchen, all minimum 6 feet tall, were not secured to the wall.
Corrective Action(s): Ensure that all furniture and equipment for use by persons in care are maintained in a safe and clean condition. The acting manager submitted a maintenance request on the second day of the inspection.
Date to be Corrected: May 31, 2018
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: The last medication room inspection was conducted in 2016. The acting manager was unable to locate the latest copy of the medication room inspection.
8 PRN medications were administered to one person in care in the month of April. Of these 8, 4 PRN medication administration were not documented with the results on the back of the MAR.
3 PRN medication protocols for one person in care were not reviewed on an annual basis, 1 from 2016, the other 2 from 2008.
Staff are to sign the MAR for signature verification. Of the 3 MAR sheets reviewed for the month of April, 2 had 9 staff signatures, and 1 only had 5 staff signatures.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: May 31, 2018
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: For 1 person in care, health care plan was due in January 2018. For a 2nd person in care, there is lacking a plan to guide staff on care such as lifts and transfers, any therapeutic interventions.
The food and nutrition forms for 2 persons in care were not completed within the last year. For 1 of the 2, forms were not completed since 2016. For the 2nd person in care, there was not a copy to review if and when they were completed. The acting manager was unable to locate the copies. This 2nd person was admitted to the facility in 2016.
Corrective Action(s): Ensure each care plan is reviewed, if necessary, modified at least once a year.
Date to be Corrected: May 2018.
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: For 1 person in care, the drinking chart states the person requires 6 cups of liquid per day. The chart is not being completed in the manner required. In the month of March, 9 days were documented with intake of 5 cups or less and for the month of April, 3 days of 9 have been documented with 5 cups or less.
Corrective Action(s): Ensure implementation of care plan by staff.
Date to be Corrected: May 31, 2018
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Substitutions are documented on a substitution list. Of 7 substitutions documented, 1 stated leftovers,1 stated an item that was not replaced with same food group item, 1 without a reason for use of the substitution.
Corrective Action(s): Ensure substitutions are made from the same food group, with a similar nutritional value.
Date to be Corrected: May 31, 2018
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: Weights for 2 persons in care have not been documented. For 1 person in care, weights were only documented 2 times last year. In addition, there was not a reason documented for why the weights weren’t taken. Discussion with the acting manager, a pharmacy that persons in care were taken to has closed. The acting manager is not aware of what has been done to rectify this. Writer contacted the licensing dietician and has provided 2 options for sites that will provide weights for those who are in a wheelchair.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: May 31, 2018
RECORDS AND REPORTING: 39580 - RCR s.91(1)(a) - A licensee must ensure that all records referred to in this regulation (a) are current.
Observation: The orientation manual for staff does not contain the most current information for persons in care. Documentation shows last updated information from 2016.
Corrective Action(s): Ensure the most current information is maintained for all records.
Date to be Corrected: May 31, 2018
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