| Holyrood Manor - Complaint Information |
| General Details | |
|---|---|
| Facility Type | Residential Care (Hospital Act) - 400 |
| Investigation Completed | January 06, 2021 |
| Reason for Investigation | - Care and supervision - Outside Licensing Mandate - Records and reporting |
| Report of Findings |
|---|
| On September 8, 2020, Licensing received a complaint alleging concerns regarding Care and Supervision and Records and Reporting. The allegations included the following details: - unexplained injury to a person in care - care plan not updated - care plan not followed in relation to feeding, medication, oral care, and supervision - inadequate staffing numbers - improperly destroyed property All areas of the complaint were fully investigated. Evidence was through interviews and a review of documentation. The following contraventions were determined: Residential Care Regulation Section 85 (1) (d) Policies Residential Care Regulation Section 81 (4) (b) (i) Care Plan Residential Care Regulation Section 68(4) Medication Safety and Advisory Committee Residential Care Regulation Section 82 Implementation of Care Plans Residential Care Regulation Section 53 Privacy |
| Substantiated Contraventions: Evidence for this summary report is based on a combination of the Licensing Officer’s observations, a review of facility records and information provided by the facility staff at the time of the investigation. |
| Observed Violations/Contraventions: A summary of the violations found during the complaint investigation are listed below. |
| Code | Category/Description |
|---|---|
| 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: Licensing determined an employee was not aware of new hold on a medication due to it not being updated accordingly. Corrective action: Corrective action required. |
| 33250 - RCR s.85(1)(c)(ii) | A licensee must do all of the following: (c) make all policies and procedures available (ii) to a medical health officer on request. Observation: Some policies and procedures were not available as required. Corrective action: Corrective action required. |
| 34150 - RCR s.53 | A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of all persons in care, ensure respect for the personal privacy of each person in care, including the privacy of each person in care's bedroom, belongings and storage area. Observation: Licensing determined the belongings of a person in care were removed and destroyed. Corrective action: Corrective action required. |
| 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: A care plan was not updated as required. Corrective action: Corrective action required. |
| 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: Licensing observed that a person in care's care plan was not implemented as required. Corrective action: Corrective action required. |
| Actions Required by Licensee/Operator | |
|---|---|
| - Corrective action plan to be developed and submitted. |
| Action Required by Licensing Officer or Medical Health Officer | |
|---|---|
| - A corrective action plan will be reviewed to ensure all contraventions are addressed. |
| Status Update |
|---|
| No further action required. All contraventions have been addressed. |
| Updated on February 03, 2021. |
