PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: In review of the physical plant, the following were noted, for example:
- One sanitizer dispenser was broken and the front portion had come off and was placed on the handrail on the 3rd floor care unit for long term care.
- When getting off the elevators to the 3rd floor care unit, one set of doors has a sofa chair placed in front of it (on the inside of the care unit) as the writer was advised the doors are not working and need to be addressed. The Manager stated last Friday, August 12, 2022 the doors were looked at and a contractor is coming in on August 23, 2022 to address this situation. Please let your Licensing Officer know on August 23, 2022 the status of the doors and whether they have been addressed. If issues arise in the interim that affect health and safety, please ensure appropriate measures are implemented.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: August 23, 2022.
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: For the hospice, for example there is the non opiod document and the evaluation section was not documented for a person in care as follows (e.g., August 14, August 11 three entries, August 10 three entries, August 4 two entries, August 5 one entry, August 6 one entry, August 7 one entry, August 8 two entries).
In addition, two medications (total two entries) for August 7 did not have staff initials documented on the front of the medication administration records.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: August 23, 2022.
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: In review of the HCA Care Flow Sheets for a person in care for July 2022, oral/dental care was not documented 4 times for days and 7 times for evenings.
Corrective Action(s): Please ensure that policies are implemented by employees.
Date to be Corrected: August 23, 2022.
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