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: The records related to medications administered to four persons in care (PIC) over the period of three months were reviewed and the following observations were made:
- On two occasions, the time an assessment was completed to determine the effectiveness of a medication was not documented on the record as required.
- On one occasion the route of a medication that was administered to a PIC was not consistent when comparing the medication administration record (MAR) and the PRN record.
- On eight occasions the administration of a PRN medication was not documented on the PRN record.
- On seven occasions the reason a PRN medication was administered was not documented on the PRN record.
- On three occasions the administration of a PRN medication was not documented in the MAR of the PIC.
Corrective Action(s): Please ensure staff implement the policies of the MSAC.
Date to be Corrected: March 8, 2023
CARE AND/OR SUPERVISION: 34560 - RCR s.75(3)(a)(ii) - If a restraint is used under section 74(1)(b) and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must (a) reassess the need for the restraint on the earlier of (ii) the time specified by the persons who agreed.
Observation: The use of two different restraints for one person in care (PIC) was to be reassessed by a specific date as per the agreement, however there was no evidence the assessment was completed as required.
Corrective Action(s): Please ensure the use of a restraint is reassessed as specified.
Date to be Corrected: March 8, 2023
CARE AND/OR SUPERVISION: 34590 - RCR s.81(2)(b) - A care plan must be developed, to the extent reasonably practical, (b) in a manner that takes into account the unique abilities, physical, social and emotional needs, and cultural and spiritual preferences of the person in care.
Observation: The records and care plans for four persons in care (PIC) were reviewed and the following observations were made:
- One PIC requires a nutritional supplement each day, however this was not included in their care plan [RCR s.81(3)(c)(ii)]. The PIC had also declined an intervention to reduce their potential to fall and had reviewed with the Licensee the associated risks, however no information regarding the agreement to live at risk was included in their care plan [RCR s.81(3)(e)(i)].
- One PIC who had a history of refusing care and physical responsive behaviors had a care plan that did not include the successful strategies developed by staff. [RCR s.81(3)(a)(ii)]
- One PIC who required medication due to their behavior needs and physical pain did not have a care plan developed to address medication [RCR s.81(3)(a)(i)] or behavior [RCR s.81(3)(a)(ii)] The PIC had also been assessed as being a risk for elopement from the facility, however did not have a care plan developed to prevent them from leaving or to locate them should they be successful [RCR s.81(3)(f)(i)(ii)]
- One PIC had recommendations made by a dental health professional during a oral health examination, however the recommendation that daily dental hygiene be provided by staff was not documented in their care plan for staff to implement [RCR s.54(3)(b)(iii)]. The PIC had a history of choking, however the ongoing risk and monitoring was not included in their care plan [RCR s.81(c)(i)]. The PICs care plan related to behaviors did not include the successful strategies developed by staff when providing care to reduce agitation and risk of harm [RCR s.81(3)(a)(ii)]. An assessment had determined the PIC was at risk for elopement from the facility, however did not have a care plan developed to prevent them from leaving or to locate them should they be successful [RCR s.81(3)(f)(i)(ii)].
Corrective Action(s): Please ensure that care plans are developed to meet the needs of the persons in care as required.
Date to be Corrected: March 8, 2023
CARE AND/OR SUPERVISION: 34620 - RCR s.81(3)(a)(iii) - A care plan must include all of the following: (a) a plan to address (iii) if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment.
Observation: One person in care (PIC) who requires the use of two different restraints did not have a care plan for the use of these restraints.
Corrective Action(s): Please ensure a care plan is developed for PICs who require the use of a restraint.
Date to be Corrected: March 8, 2023
CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (ii) a plan for preventing the person in care from falling.
Observation: Care plans for four persons in care (PIC) were reviewed with the following observations made:
- 1 PIC with a history of recent falls, did not have a care plan to assess the risk of, prevention of and the response to falls.
- 1 PIC who had several strategies in place to prevent and/or reduce injury from falls, did not have a care plan to assess the risk of, prevention of and the response to falls.
Corrective Action(s): Please ensure all persons in care have a fall prevention plan that meets the requirements.
Date to be Corrected: March 8, 2023
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: The medical records of four persons in care (PIC) were reviewed and the following observations were made:
- One PICs Immunization screen had not been completed in full.
- One PIC required follow up to be completed regarding their tuberculosis screening, however there was no evidence it was completed as required. Their immunization screen was not completed in full.
- One PIC had no evidence that the immunization or tuberculosis screen had been completed.
Corrective Action(s): Please ensure all PIC comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: March 8, 2023
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