STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: It was determined that the probationary performance reviews for the approximately 20 staff hired in 2020 for kitchen, laundry and housekeeping were not completed. In addition, in an audit of 6 care staff files, 2 performance reviews were observed as overdue.
Corrective Action(s): Ensure regular performance reviews are conducted.
Date to be Corrected: April 5, 2021
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: Review of medication administration, determined one medication cart was not locked when staff stepped away to administer medication. As well, one medication transcribed wrong in the narcotics chart, when the transfer of information occurred into a new system.
Corrective Action(s): Ensure all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: April 5, 2021
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Review of policies and procedures, confirmed a review has not been conducted by the licensee in the previous year, most recent confirmed date was 2019 for one policy and others audited were 2017, although the Resident Services Manager reviewed required policy, of concern if other policy around care and services, one example being emergency planning.
Corrective Action(s): Ensure the polices and procedures are reviewed at least once each year.
Date to be Corrected: April 5, 2021
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: Review of resident charts determined several documents are not completed consistently. These documents include pre-admission checklists, admission day interviews, falls risk assessments, ADL flowsheets, COVID - 19 screening checklist, clothing label sheets. In some cases, the corresponding required documents were in place. As well, review of staff files and policy on orientation and training confirmed that 3 staff files did not have confirmation of orientation and training.
Corrective Action(s): Ensure employees implement policies and procedures.
Date to be Corrected: April 5, 2021
CARE AND/OR SUPERVISION: 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: one fall care plan can not be determined if it is being followed. For example, implementation of the placement of the fall mats is not consistently recorded in the ADL sheet to ensure implementation of the care plan. As well, for two persons in care, the wound care plans were not documented to be following the timelines for dressing changes, inturn it appears not to be implemented as required.
Corrective Action(s): Ensure the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Date to be Corrected: April 5, 2021.
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: It would not be determined from two persons in care admitted, complied with the Provinces TB control programs. For two persons in care, there lacked immunization records or documentation was incomplete.
Corrective Action(s): Ensure all persons in care admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: April 5, 2021
RECORDS AND REPORTING: 39410 - RCR s.86(a) - A licensee must keep the following records in respect of each employee: (a) criminal record check results,.
Observation: For two staff, there lacked the confirmation of their professional registration which would in turn confirm CRC results.
Corrective Action(s): Ensure records respecting the employee to meet the requirements of this legislation
Date to be Corrected: April 5, 2021
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