LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: An audit of call bell response times has not been completed. The quality assurance team confirmed there is no effective auditing system in place for the following: admission process, medication delivery, care plan system. For example Care plans and ADL’s did not match in 7 out of 7 care plans reviewed.
•A person in care, who was at risk for choking and received a pureed textured diet with thickened fluids, did not have diet information documented on their ADL sheet.
•A second person in care, who received a pureed texture diet with thickened fluids, did not have thickened fluids documented on their ADL sheet. In addition, this person in care had swallowing issues, which were not recorded on their ADL.
•A third person in care, who was at risk for choking and received a pureed texture diet. did not have this information documented on their ADL sheet. Their ADL sheet documented that they received a regular cut-up texture diet.
Corrective Action(s): Please ensure that care and services are monitored regularly to ensure the requirements of the Act and Regulations are being met.
Date to be Corrected: Immediate
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: A toilet had wet/ soiled towels hanging across the toilet seat
Two bedrooms had damage to the paint and drywall damage from what appeared to be repeated contact with a wheelchair and bed. (Correction: by April 10, 2020)
A person in care’s room had 13 bottles of oxygen standing upright and unsecured. These bottles were located inside the room and near the entrance. It is a concern that they may fall over and become a tripping hazard, as they are located near a high traffic area. It is also of concern that compressed gas is being stored in a person in care’s room (Correction: Immediate)
Corrective Action(s): A licensee must ensure room and common areas are maintained in a safe and clean condition.
Date to be Corrected: see date in observation section above
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31310 - RCR s.22(2) - A licensee must ensure that emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency.
Observation: : Five or more persons in care’s rooms could be secured from inside their rooms using a clip, rope, and latch. This mechanism was located 4 to 5 feet off the floor. Slack on rope allowed the door to be partially opened from the outside, allowing staff to reach inside and release the clip from the latch. However, this mechanism may hinder a person in care from exiting their room in the event of an emergency .
Corrective Action(s): Please ensure that persons in care are not restricted from exiting the facility in the event of an emergency.
Date to be Corrected: Immediate
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: Two of 17 staff did not have a current criminal record check on file.
Corrective Action(s): Please ensure that all staff have a current criminal record on file.
Date to be Corrected: April 10, 2020
STAFFING: 32040 - RCR s.37(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: No staff working the night shift had a valid first aid certificate.
Corrective Action(s): Please ensure that persons in care have immediate access to a staff with a valid first aid certificate.
Date to be Corrected: Immediate
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: As per facility policy performance reviews are to be completed annually. Four of 5 staff files did not show evidence of a regular performance evaluation.
Corrective Action(s): Ensure that staff’s performance is regularly evaluated to ensure that they continue to meet the requirements of this regulation. Please complete a total review/audit of staff files, and prioritize any significantly overdue staff files for correction (by May 15, 2020), and submit a plan to licensing to complete an update of all performance reviews and staff files.
Date to be Corrected: May 15, 2020
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: On multiple occasions, staff had administered medications not within the 30 minute window given in the Medication Safety Advisory Committee’s [MSAC] policies and procedures.
The MSAC policies and procedures required double signatures for the drawing and administering of insulin; however, staff were completing this process only 50% of the time.
Corrective Action(s): Please ensure that staff implement the MSAC’S policies and procedures.
Date to be Corrected: Immediate
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: Three clinical staff were unable to access the catheterization policy and procedure to guide them in providing care.
Corrective Action(s): A licensee must have written policies and procedures for the purpose of guiding staff in all matters related to the care and supervision of persons in care.
Date to be Corrected: April 10, 2020
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: According to the Licensee’s policies and procedures, staff were to document wound care in a specific binder. The Quality Assurance team confirmed that this documentation was not located in this binder.
Corrective Action(s): A licensee must ensure policies are implemented by employees.
Date to be Corrected: April 10, 2020
CARE AND/OR SUPERVISION: 34370 - RCR s.63(3)(c)(iv) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iv) reassessed by the person in care's medical practitioner, nurse practitioner or dietitian at least once every 30 days.
Observation: : The On-going meal tray service, monthly assessment form for one person in care requiring tray service was not signed for the months of February and (March 2020).
Corrective Action(s): Please ensure that, for persons in care receiving tray services, a medical practitioner, nurse practitioner, or dietitian assess and, thereafter, reassess tray services at least every 30 days.
Date to be Corrected: April 10, 2020
CARE AND/OR SUPERVISION: 34610 - RCR s.81(3)(a)(ii) - A care plan must include all of the following: (a) a plan to address (ii) behavioural intervention, if applicable.
Observation: Incidents of aggression, both verbal and physical, were documented in a person in care’s progress notes; however, there was no evidence that staff completed a behavour risk assessment and tracking form, or updated the care plan to include a behavioural invention plan, and implement a purple dot alert system.
Corrective Action(s): A care plan must include a behavioral intervention if applicable.
Date to be Corrected: April 10, 2020
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: The Quality assurance team found that the care plan for one person in care indicated that a pressure relieving device was not used, however the person in care had a ROHO cushion in place
Corrective Action(s): A licensee must ensure that each care plan is reviewed, and if necessary modified if there is a substantial change in circumstance of the person in care.
Date to be Corrected: April 10, 2020
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: Two persons in care have a risk agreement in place pertaining to eating at risk, and do not have evidence of review or consents obtained in the past 12 months.
Corrective Action(s): Risk agreements are to be reviewed and signed annually with the persons in care and/or their representatives with the appropriate chart documentation.
Date to be Corrected: April 10, 2020
CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Observation: A review of weight records from December 1, 2019 until February 29, 2020 determined the following weights were missing without a reason documented:
December 2019- 3 missing weights
January 2020- 2 missing weights
February 2020- 1 missing weight
Corrective Action(s): Please ensure that each person in care is weighed monthly, as per the Licensee’s policy and procedure.
Date to be Corrected: April 10, 2020
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: A person in care’s family provided a supplement, which was being administered as a medication. The pharmacy had not labelled or packaged this supplement and it did not have a drug identification number.
Corrective Action(s): Please ensure that the pharmacist packages and labels all medications administered to persons in care.
Date to be Corrected: April 10, 2020
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