During the resident file audit process, a resident was observed sitting in a wheelchair in front of a table in the dining area beside the nurse's station. There were 3 other residents similarly seated. The area is open and staff were entering and leaving the station from either side of the desk. The resident was heard to request assistance or attention in a moderate, but audible voice, from 3:10 when the LO arrived to 4:00 when the LO left the area. It is a concern that this resident appeared to have no activities, no one stopped to talk with the resident or check why the resident was calling out.
This incident was discussed with one of the clinical care coordinators. The resident's needs and interventions to date were discussed. The CCC stated that the family is actively involved with the care of this resident. While the resident had been assessed by psychiatry, there had been no assessment or recommendations by a behavioralist. Given the absence of activities observed during the incident the LO brought the incident forward to the volunteer/activity coordinator who indicated that sometimes a volunteer is assigned to residents who have need of more frequent 1:1 attention.
Please provide a response that will confirm that there is planning in place for all persons, such as this resident, to provide monitoring per RCR 50(1), code 34090 to ensure their needs are met for April 16, 2018
The DOC was only aware of 2 fire drills per year that take place. A telephone interview with the Manager of Security Services was conducted. It was confirmed by the security manager that there are 3 drills scheduled monthly. Two drills are 'non-live' and one drill is live where the response is acted out by staff. Additional drills can be conducted on request if the staff response to the drill is not deemed effective. The results of the drills and the attendees are documented. The documentation is entered into the SSIRS, the security database. The responses are analysed to determine need for further staff training.
The manager also discussed the available resources to be deployed by the security company in the event of a disaster. Discussion included description of a fan-out list of Eagle Ridge staff that would be called out by the company operation centre or dispatch centre, other resources include 22 mobile units, managers and a base of 3,000 staff from the security company, available to cover different shifts and provide assistance. In the event of a disaster an on-site field officer, available 24/7 can access other field officers to act in supervisory capacities. This appears to meet the intent of RCR 51(3) but appears to be a response intended for the Eagle Ridge site as a whole.
Please provide a response to clarify the the training provided to the staff to respond to the initial occurrence ( first hour)of an emergency (eg fire) at the Eagle Ridge Manor site only by April 16, 2018.
A medium sized upholstered occasional-style chair was observed in front of a fire exit. The chair is light and easily moved. The manager stated that visitors often move the furniture from the rooms and may have left it there. In the case of an urgent evacuation, it could act as an unnecessary obstacle. No signage with large writing was observed to tell people not to obstruct fire exit. As well, multiple (3-4) bed storage at the end of a hall that was observed encroaching on a fire exit and was identified to the CCC. The CCC had previously checked about the bed storage with the security manager and was told that as long as they were on wheels it was acceptable. While this may be acceptable practice it does not meet the intent of:
RCR 22 (2) A licensee must ensure that emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency
(3) A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Please provide a response that will demonstrate how the intent of the above legislation can be met for April 16, 2018.
The new admissions or their representatives are requested to sign a consent for dental treatment. For residents who do not provide consent or for residents who cannot afford to pay for treatment, the social worker is available to facilitate the resident to receive appropriate professional interventions and avoid financial hardship.
The volunteer manager was interviewed. It appears that the appropriate screening as per Residential Care Regulations (RCR) 37(3)(a)(b) are being carried out as well as Tb screening. The manager expressed difficulty in obtaining immunization screening as many of the volunteers are immigrants. It was discussed that Canada Immigration has standards for immunization screening before accepting new immigrants to the country. The manager will contact immigration to determine if there are standards that can be assumed for new immigrants. In the meantime, a list of Provincial Immunization standards and an example of the immunization and Tb checklists for patients were provided. Follow-up on this point will occur by the volunteer manager as well as this LO. The volunteer services co-ordinator will check with Immigration Canada about Immunization standards. A checklist for status of immunization and TB was provided.
Dietary service was reviewed. The kitchen is operated by a dietitian. Audits are conducted, ethnic style foods are prepared on request as well a foods recognizing ethnic celebrations, eg Chinese New Year and St. Patrick's Day. The dietitian was observed providing education to staff during a staff meeting when LO arrived to interview the dietitian. Food is served on trays to the PICs whether in their room or in the dining room. Some persons/families choose to eat at risk, alone in their rooms. There are staff who regularly check on the residents during meals. Meals contain 3 food groups and snacks contain an offering of 3-4 food groups on a tea trolley. The dietitian is very conscious of the desire for some residents to have a "sweet" for snacks. The grain food group might be cake or cookie.
The residents and representatives/families are made aware of the comfort fund on admission to the facility. The comfort fund is managed by the cashier in the hospital building. For outings the Activity staff may withdraw funds for the event, eg lunch out, and the change for the withdrawal is replaced to the cashier. It was unclear whether the cashier required a receipt with the returning funds.
Wound care was not reviewed at this inspection, and will be reviewed on subsequent inspection.
I would like to thank the staff and residents who were an extremely helpful part of this inspection.
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