The following was reviewed and noted:
Review of the tub rooms noted that doors were closed and re-education with staff had occurred. Upon inspection, two tub rooms were closed and secure.
Review of the medication storage room found that there were no personal items being stored and discussion with the Manager confirmed that staff store personal items in a separate area. Discussion with the Manager determined that a review of the policy did not state that purses could not be stored in the medication room, the policy specified lunches not to be stored in the medication fridges.
Fire extinguishers are annually checked and it was determined that this is completed on a regular basis.
Discussion with the Registered Dietician (RD) noted that referrals are made through PCC 'secured conversations' and flagged for RD's review. It was discussed that these conversations will be removed after time and it was recommended that there is a system in place to ensure that referrals are documented and kept on record to ensure that the referral process is captured.
Review of staff files determined that staff professional registrations are updated/completed each year and are presented on a spreadsheet from Human Resources.
The PIC that did not have a photo on their PCC/care plan, did have a photo taken on the day they were admitted but the photo was not immediately downloaded to PCC system. Photos for persons in care (PIC) are taken and immediately uploaded to the PCC system.
Discussion with the Manager determined that all PIC's have documentation showing compliance with the Province's Immunization control program.
This LO would like to thank the Manger and Director of Care for their time and assistance in completing this follow up inspection.
This report was reviewed and discussed with the Manager and Director of Care. A copy of this report was left at the facility.
Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
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