POLICIES AND PROCEDURES: 33150 - RCR s.68(3(b)(ii) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (ii) the immediate response to and reporting of medication errors and adverse reactions to medications.
Observation: On review of the Minutes from the most recent MSAC meeting, it was observed that there was no review of medication errors reporting and adverse reactions by the MSAC.
Corrective Action(s): Please provide a plan that will ensure that the intent of the regulation is being met by the MSAC committee.
Date to be Corrected: Sept. 20, 2017
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: Policy and procedure binder was reviewed. The facesheet that defines the Policies and Procedures located at the front of the binder indicated that the most recent review of P&P occurred in 2015.
Corrective Action(s): Please provide a plan that will ensure that all policies are reviewed and if required revised once per year.
Date to be Corrected: Sept. 20, 2017
CARE AND/OR SUPERVISION: 34220 - RCR s.56(1) - A licensee must ensure that a person in care who leaves a community care facility for a temporary purpose has in his or her possession written documentation indicating the person in care's name, the community care facility's name and emergency contact information.
Observation: The off-site identification card of the newest resident was reviewed and continued to have contact information for the previous facility. As well the photo was older and did not reflect the resident's present appearance.
Corrective Action(s): Please review the identification of all residents to ensure their contact information and photos are up to date and reflect the present appearance and location of the resident.
Date to be Corrected: Sept. 20, 2017
NUTRITION AND FOOD SERVICES: 37210 - RCR s.67(1)(a) - A licensee must provide each person in care with (a) nutrition supplements required by the person in care's nutrition plan or ordered by the person in care's medical practitioner or nurse practitioner.
Observation: A nutritional supplement (thickener) was observed for 2 residents. One resident is funded for the product The second resident pays for their own product even though it was ordered by the dietitian and cosigned by the Dr. while product approval is pending.
Corrective Action(s): Please provide a plan that will ensure that the licensee "provides" nutritional supplements to all residents who require a nutritional supplement.
Date to be Corrected: Sept. 20, 2017
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