| Belvedere Care Centre - Complaint Information |
| General Details | |
|---|---|
| Facility Type | Residential Care (Hospital Act) - 400 |
| Investigation Completed | November 26, 2019 |
| Reason for Investigation | - Staffing - Policies and procedures - Care and supervision - Hygiene & communicable disease control - Medication |
| Report of Findings |
|---|
| On August 16th, 2019, Licensing received a complaint alleging concerns regarding care and supervision. The allegations included the following details: - A care plan was not followed - Inadequate care was provided to a person in care - There is inadequate staffing to meet persons in care's needs - A person in care sustained injuries while in care All areas of the complaint were fully investigated. Evidence was received and reviewed from records, policies and procedures, inspection, interviews, and emails. The following contraventions were determined: - Residential Care Regulation, Section 85(1)(d), Policies and Procedures - RCR, Section 82 Care Plan Implementation of Care Plans - RCR, Section 40 (3) Continuing monitoring of employeees |
| 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 |
|---|---|
| 32120 - RCR s.40(3) | A licensee must not permit an employee to carry out any duties for which the employee does not have the necessary training and experience or demonstrate the necessary competence. Observation: Staff did not demonstrate necessary competence in ensuring that a care plan was followed. Corrective action: The Licensee submitted a corrective action plan, which addressed all contraventions. |
| 33170 - RCR s.74(1)(b)(i) | Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care. Observation: Licensing determined that staff used a restraint without required agreements. Corrective action: The Licensee submitted a corrective action plan, which addressed all contraventions. |
| 33280 - RCR s.85(1)(d) | A licensee must do all of the following: (d) ensure that policies are implemented by employees. Observation: Licensing determined that staff did not follow policies and procedures. Corrective action: The Licensee submitted a corrective action plan, which addressed all contraventions. |
| 34470 - RCR s.73(2)(c) | In addition to the requirements under subsection (1), the following conditions apply to the use of a restraint under section 74(1)(b) [when restraints may be used]: (c) the use of the restraint, its type and the duration for which it is used must be documented in the care plan of the person in care. Observation: Restraint use was not documented in a care plan. Corrective action: The Licensee submitted a corrective action plan, which addressed all contraventions. |
| 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: Staff did not follow a PIC ’s care plan. Corrective action: The Licensee submitted a corrective action plan, which addressed all contraventions. |
| Actions Required by Licensee/Operator | |
|---|---|
| - Corrective action plan to be developed and submitted. - A corrective action plan was submitted. No further action is required. |
| Action Required by Licensing Officer or Medical Health Officer | |
|---|---|
| - Review and monitor corrective action plan > Follow up inspection required. |
