LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: A random review of two charts to review the records of care and also a random review of the records of care binder at the nurses station on the main floor by the front entrance indicated and was also discussed with the Director of Care (specific examples provided):
- If a person in care is independent with oral / dental care, this is not documented in one chart whereas it is documented in another chart.
- Some entries for example for oral / dental care for day shift not initialed by the staff.
A review of two charts and also the personal hygience checklist binder to review the bathing assessment forms indicated on the back of these documents the staff have not signed off. The Director of Care was given specific examples and will follow-up.
Corrective Action(s): Please ensure as per section 61 of the Residential Care Regulation that staff are thoroughly documenting on forms in it's entirety.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31140 - RCR s.19(1)(a) - If a person in care requires monitoring, or a signalling device, to ensure that person's health and safety, a licensee must provide a monitoring system or signalling device that (a) is appropriate to the needs of the person in care.
Observation (CORRECTED DURING INSPECTION): A random review of the persons in care bedrooms indicated in one bedroom the call bell was in-place, however the cord from the call bell was not. The Interim Manager had the Maintenance Staff address this and was corrected during the inspection. The Maintenance Staff was in the process of checking all the bedrooms to ensure the call bell and cord are in-place so persons in care have access in case they need it.
Corrective Action(s): To ensure health and safety please ensure call bells are appropriate to the needs of the person in care and can be used accordingly.
Date to be Corrected: Please provide an update on this item if there are any other call bells with no cords, etc and the plan to address this as the Maintenance Staff was in the process of reviewing all the bedrooms.
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: When leaving the main dining room on the lower level to the outside courtyard, the tiles on the floor/bricks on the floor outside the door to the courtyard are uneven and can potentially cause injury to a person in care. The Interim Manager stated they are aware of this and there are plans to address this.
Corrective Action(s): Please ensure all common areas are maintained in a good state of repair.
Date to be Corrected: Please provide a written response by the timeline noted in this report.
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: A random review of the medication systems at one nurses station indicated, for example:
- A medication on the front of the medication administration record was not initialed for. The specifics were provided to the Director of Care.
- PRN (as needed) medications not noted with the results/effects on the back of the medication administration records. The specifics were provided to the Director of Care.
Corrective Action(s): Please ensure all staff are following and complying with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
CARE AND/OR SUPERVISION: 34630 - RCR s.81(3)(b) - A care plan must include all of the following: (b) an oral health care plan.
Observation: A random review of five care plans indicated one care plan did not have a oral care plan component. The Director of Care stated they will have this addressed.
Corrective Action(s): Please ensure all persons in care have a oral care component in-place as part of their care plan.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: A random review of 4 staff files indicated for one file there is a tuberculosis record, however no indication of an x-ray result which is not on file.
Corrective Action(s): Please ensure all staff have a tuberculosis clearance on file (Previously the writer sent to all of their facilities the Tuberculosis and Immunization Guideline for staff).
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: A random review of five persons in care charts indicated for one person in care their immunizations are not in-place. The Director of Care stated they will follow-up on this.
Corrective Action(s): Please ensure all persons in care have immunizations documented.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: A random review of the personal hygiene checklist/monthly weights binder at one nurses station indicated for a person in care one weight was not documented after it was confirmed it is also not documented in another area as well. The Director of Care stated they will follow-up on this.
Corrective Action(s): Please ensure monthly weights are monitored and documented accordingly.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: In review the nutrition audits binder, there is a schedule of the audits that need to be completed throughout the year. For example, April 2017 Dining Environmental Audit not in-place or Hydration Program Audit for June 2017 not in-place. The Director of Care has followed up with the Food Services Manager to follow-up on this.
Corrective Action(s): Please ensure the nutrition audit schedule of audits to be completed is being followed through as required and audits completed accordingly.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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