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: Random audit of 4 person in care's (PIC) medication administration records it was observed that for one PIC staff signed for medication being administered (2000 hour/July 16, 2016), however the full medication pouch was observed in his medication box and the staff working during this inspection confirmed he was on a social leave and the appropriate number should have been documented not the staff signature.
Corrective Action(s): Please ensue staff comply with policies and procedures for medication administration.
Date to be Corrected: July 20, 2016
CARE AND/OR SUPERVISION: 34640 - RCR s.81(3)(c)(i) - A care plan must include all of the following: (c) a nutrition plan that (i) assesses a person in care's nutrition status.
Observation: Random audit of 4 person in care's recovery/care plans it was observed that one person in care was missing a completed nutritional assessment and his weight chart was incomplete (missing ideal/goal weight).
Corrective Action(s): Please ensure an assessment is completed to provide a baseline for monitoring nutritional status and weight.
Date to be Corrected: July 22, 2016
RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: One of four person in care records reviewed - 1 person's records did not include evidence of TB screening and immunization status.
Corrective Action(s): Please ensure TB screening and immunization status is obtained and placed on their record.
Date to be Corrected: July 22, 2016
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: One of 4 person in care's records reviewed did not have consent as noted above.
Corrective Action(s): Please ensure consent is included in person in care's records.
Date to be Corrected: July 22, 2016
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