LICENSING: 30200 - RCR s.12(2) - If requested by a medical health officer, a licensee who is being investigated must provide to the medical health officer a plan to ensure the health and safety of persons in care during the investigation.
Observation: The Health and safety plan/action plan that was accepted by Licensing and Quality Assurance was breached regarding the auditing of the wounds and the completion of daily wound care binder audits.
The health and safety plan/action plan was that the facility would be responsible for conducting wound care audits. On follow up by QA, there have been no wound audits.
Corrective Action(s): The Licensee is responsible to ensure the accepted Health and Safety Plan is maintained and monitored for effectiveness, until such time as you receive notification from licensing that it can be removed or modified. If changes to the Health and Safety Plan are needed, your request must be discussed and accepted by licensing prior to implementing the modified plan.
Date to be Corrected: Immediate. Submit a plan to licensing that will ensure that any and all health and safety plans will be monitored to ensure implementation.
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: Quality Assurance review of care plan documentation found some "informal" auditing being completed but no formal documentation is completed for any of audits. QA determined that any auditing that has been done is ineffective. Due to amount of contraventions on this routine inspection that include many different systems, licensing has also determined that the site's own self-monitoring systems are inadequate and ineffective.
Corrective Action(s): Please ensure that there is effective regular monitoring of the community care facility and the care services provided by it to ensure that it meets all of the requirements of the CCLA and RCR.
Date to be Corrected: Immediate. Submit to licensing a plan to immediately review and update all auditing and monitoring on site to evaluate gaps and update them to ensure ongoing compliance in all areas.
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: Four of 13 staff files reviewed did not include evidence of criminal record checks completed within the last 5 years.
Corrective Action(s): Please ensure that a criminal record check in good standing is obtained for each staff. Submit to licensing a plan to review all staff files to ensure CRC’s are current, and ensure that all CRC’s are submitted by the correction date.
Date to be Corrected: April 10, 2020
STAFFING: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: Four of 13 staff files reviewed did not include any evidence of references.
Corrective Action(s): Please ensure that references have been obtained for recently hired staff prior to their employment, and provide licensing a plan to ensure references are obtained for all new staff.
Date to be Corrected: April 10, 2020
STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Five of 13 staff files reviewed did not include evidence of a TB screening. Four of 13 staff files reviewed did not include evidence of staff’s immunization status.
Corrective Action(s): Please ensure that staff have provided evidence of immunization and completing the TB screening process. Completing this process should be completed prior to a staff’s employment.
Date to be Corrected: Submit to licensing a plan to review all staff files. Ensure records are updated by April 10, 2020.
STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: Ten of 13 staff files reviewed did not include evidence of a regular performance evaluation. Facility policy states that performance reviews are to be completed yearly and this had not occurred.
Corrective Action(s): Please ensure that staff’s performance is regularly reviewed to ensure that they continue to meet the requirements of the Residential Care Regulation. Please complete a total review/audit of staff files, and prioritize any significantly overdue staff files for correction (by May 15, 2020), and submit a plan to licensing to complete an update of all performance review and staff files.
Date to be Corrected: May 15, 2020
STAFFING: 32180 - RCR s.42(1)(b) - A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to (b) assist persons in care with the activities of daily living, including eating, moving about, dressing and grooming, bathing and other forms of personal hygiene, in a manner consistent with the health, safety and dignity of persons in care.
Observation: Based on a review of the staffing schedule for Health Care Aides (HCA) and Nursing staff from February 13, 2020 until March 6, 2020, approximately 16 HCA shifts and 1 Nursing shifts were not filled. This number is an approximate due to the manner in which the schedule was recorded.
However, other information (as documented below) confirmed that staff coverage was, at times, insufficient to meet the needs of persons in care.
· Staff spoken with during this inspection stated that they worked without a full complement of Health Care Aides (HCA) staff on a regular basis.
· A HCA staff day shift on March 6, 2020 was not filled.
· A family member arrived at the facility at 1:30pm and observed that a person in care was lying on a urine soaked mattress on their back with the lunch tray in front of them, even though the persons in care was required to be repositioned to their side. The reason given for this requirement not being met was that a full complement of staff was not available on this floor.
· HCA staff occasionally needed to complete 2 person sit-to-stand lifts as a 1 person lift or they needed to have some persons in care eat breakfast in bed, as they needed to delay assisting some persons in care morning care until a 2nd staff was available to assist them. (Licensing gathered this information after speaking to a number of persons in care and staff.)
Please ensure that staff coverage is sufficient and organize in manner to meet persons in care’s need to for care and supervision.
Corrective Action(s): Please ensure that staff coverage is sufficient and organized in manner to meet persons in care’s need to for care and supervision.
Date to be Corrected: Immdiate. Submit a plan to licensing that includes a review of the staffing schedule to ensure staff coverage is sufficient to meet persons in care needs to comply by April 10, 2020.
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: Staff working the overnight shift on March 5, 2020 and March 6, 2020 did not have evidence of a valid first aid certificate. There was no system in place to ensure that a staff with a valid first aid certificate was working each shift.
Corrective Action(s): Please ensure that persons in care have immediate access to a staff with a valid first aid certificate. Submit a plan to licensing that confirms when a review of all staff first aid dates will be completed and date(s) that first aid training will occur for staff who require it.
Date to be Corrected: Immediate
STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: Review of emergency plan on all three floors, found no documentation to confirm that employees were trained in the implementation of the emergency plan and use of equipment. Discussion with staff confirmed that one fire drill had been completed, as a person in care had pulled the fire alarm. The staff was unable to confirm that any other fire drills and other emergency preparedness drills have been completed within the last year.
Corrective Action(s): Please ensure that staff are trained in the implementation of the emergency plan.
Date to be Corrected: Submit a plan to licensing to outline the training that will be provided to all staff on the emergency plan, including dates. Ensure that training is provided by April 30, 2020
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: Medication Safety Advisory Committee (MSAC) medication policies and procedures required that medications were administrated within a “window” – 30 minutes before and after a medication dosage time. Five of 19 recorded medications had been administered more than 1 hour after a dosage time.
According to the MSAC’s policies and procedures, narcotic counts were to be completed at the end of each shift (3 times per day). During the month of February and March 2020, these counts were being completed inconsistently, where some counts were being completed between 1 and 4 times per day.
Staff must be aware of the MSAC policies and procedures in order to implement them. Staff working at the facility acknowledged that they had not read the MSAC policies and procedure and they were not aware of where to find these policies and procedures. Discussion with another staff confirmed that the MSAC policies and procedures were not referred to and consistently not available for review. At the time, staff could not locate the MSAC polices and procedures.
Corrective Action(s): Please ensure that staff know how to access the policies, know where the policies are located, and to implement the policies and procedures of the MSAC when needed.
Date to be Corrected: Immediate. Submit a plan to licensing that outlines the review of MSAC policies with staff, the availability of policies and an audit and sustainability plan to ensure ongoing compliance.
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: Review of four of 31 restraint documentation for three persons in care found that consent had not been obtained from the person in care’s representative.
Corrective Action(s): Please ensure restraint documentation is complete.
Date to be Corrected: Submit a plan to licensing that includes a review of all restraint documentation, and an audit and sustainability plan to ensure ongoing compliance by April 10, 2020.
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: Review of four of 31 restraint documentation for three persons in care found that consent had not been obtained from the person in care’s representative.
Corrective Action(s): Please ensure that restraint documentation is complete.
Date to be Corrected: April 10, 2020
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: Quality Assurance (QA) team reviewed 1 admission documentation and the facility staff reviewed 3 admission documentation and found that the documentation for all four incomplete. QA determined that the facility staff did not follow their policy and procedure for facility admissions.
Corrective Action(s): Please ensure that staff follow their admission policy and procedure and that all admission documentation is complete.
Date to be Corrected: Immediate. Submit a plan to review the admission process and include follow up that will occur to ensure ongoing compliance.
CARE AND/OR SUPERVISION: 34370 - RCR s.63(3)(c)(iv) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iv) reassessed by the person in care's medical practitioner, nurse practitioner or dietitian at least once every 30 days.
Observation: Review of two of 31 care plans found that there was no evidence that a medical practitioner, nurse practitioner, or dietitian had reassessed ongoing tray services received for one person in care for the months of February and March 2020. The criteria as to who reassesses the need for ongoing tray service on the existing forms were not consistent with Licensing’s guidelines concerning tray services. This contravention was documented in a routine inspection completed in 2019 (a repeated contravention).
Corrective Action(s): Please ensure that a medical practitioner, nurse practitioner, or dietitian has reassessed ongoing tray services at least every 30 days.
Date to be Corrected: Immediate. Submit a plan to licensing that includes review of all persons in care (PIC) care plans to ensure any PIC with ongoing tray service has the correct documentation. Include a sustainability plan to ensure ongoing compliance.
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: Review of 31 care plans, activity of daily sheets (ADL) sheet, diet lists and other information associated with care plans provided inconsistent information for 85% of the persons in care reviewed.
For example, a person in care’s wound care plan documented that they were to be in bed for 2 to 3 days, the practitioner’s orders was for 4 days, and information posted on the person in care room’s wall recorded 4 days. The plan also included that the person in care was to be repositioned every 2 hours, but staff had not documented that the reposition had occurred on 2 days and only documented that it occurred 50 percent of the time on the other 2 days. This information demonstrated that care plan were not being monitored on a regular basis to ensure proper implementation.
While reviewing a care plan for one person in care, it was noted that there was no ADL sheet in the person in care’s room, and that wound care documentation was not found in the designated wound care binder. Review of the progress notes on the computer system identified that one wound was healed but identified a new wound that was not captured in the care plan, or the wound care binder, or by the staff. Further review, found that the wound was documented in the progress notes as being on the wrong arm.
Review of progress notes for one wound, determined that a nutritional supplement was discontinued as the person in care was no longer taking the supplement. A progress note written four days after, lists the nutritional supplement as part of the wound care protocol for healing. It could not be confirmed if the supplement was discontinued or still on-going based on the care plan documentation.
Corrective Action(s): Please ensure that care plans are monitored on a regular basis for proper implementation.
Date to be Corrected: April 10, 2020
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: A review by Quality Assurance of 5 person in care files, determined that there had been significant changes in the circumstances for person in care and this was not updated in their care plans. The following are examples that were noted by QA:
· One person in care had a plan in place for a wound that no longer existed
· Two persons in care had a wound care plan in place for a single wound but both persons in care had multiple wounds that were not identified
· One person was identified as a fall risk on the care plan but this was not identified on the Activities of Daily Living (ADL)
· One person in care was identified as having a Negotiated Risk Agreement on the chart by this not included in the care plan
Corrective Action(s): Please ensure that if there is a substantial change in the circumstances of the person in care that the care plan is modified to reflect these changes.
Date to be Corrected: Immediate. Submit a plan to licensing that includes immediate review of all care plans to ensure they are current, and being implemented correctly
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: Dietary preferences based on nutritional requirements for one person in care was not implemented and this was confirmed by both the person in care and staff. (Corrected During Inspection).
Corrective Action(s): Please ensure that care plans are implemented as required.
Date to be Corrected: Immediate
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: Review of 31 care plans found that three persons in care had no documentation/record of compliance with BC immunization and TB programs. Further review of the TB/Immunization documentation found that most documentation had been partially completed, and not completed by the person in care, the persons in cares representative, or the facility.
Corrective Action(s): Please ensure that all persons in care have evidence of compliance with BC Immunization and TB programs.
Date to be Corrected: Submit a plan to licensing for review of all care plans to ensure appropriate documentation. All records must be update by May 13, 2020.
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: The fridge and freezer temperatures were not monitored in 1 servery for 4 days. All 3 serveries had temperature recordings for the fridge and freezer temperatures which were too high for the safe storage of food. Temperatures were above the safe food storage temperature of 0-4 degree Celsius. This contravention was documented in a routine inspection completed in 2019 (a repeated contravention).
Corrective Action(s): Please ensure that all food is safely prepared, stored, served and handled.
Date to be Corrected: Submit a plan to licensing on what training will be provided and the system put in place to ensure the safe storage of food. Ensure this is in place by April 10, 2020
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation (CORRECTED DURING INSPECTION): Review of one of 19 medications, found expired PRN medications in a person in care’s non-expired supplies of medications. One package of these medications had been opened and the tablets had been crushed. This package had not been removed.
Corrective Action(s): Please ensure that expired medications are separate from non-expired supplies of medications and these expired medications are returned to the pharmacy.
Date to be Corrected: Corrected During Inspection
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: QA determined that two reportable incidents that are required to be reported to Licensing, were not completed. This included a influenza outbreak and an unexpected illness that required a person in care's transfer to hospital.
Corrective Action(s): Please ensure that licensing is immediately notified for all reportable incidents.
Date to be Corrected: Immediate.
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: Four of 19 person in care’s weights had not been recorded for August 2019, September 2019, November 2019, January 2020, and February 2020. There was no reason why the weight was not obtained.
Corrective Action(s): Please ensure that a record of monthly weights is maintained for each person in care or the reason why the weight was not obtained is documented.
Date to be Corrected: Immediate. Submit a plan to licensing that includes a review of weighing, the recording of weights and the audit to ensure ongoing compliance.
RECORDS AND REPORTING: 39340 - RCR s.84(a) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (a) the type or nature of the restraint used.
Observation: Review of 19 care plans found the use of one restraint (pin-lock) was being used as a restraint for a person in care; however, the person in care’s care plan did not document the type and nature of this restraint.
Corrective Action(s): Please ensure that restraint documentation is complete an included in the in the care plan.
Date to be Corrected: Immediate. Submit a plan to licensing that includes a review of persons in care to ensure any restraints have appropriate approvals and documentation in place.
RECORDS AND REPORTING: 39480 - RCR s.87(d) - A licensee must keep a record of the following matters respecting food services: (d) food services and nutrition care education and training programs attended by food services employees.
Observation: There are no records of on-going education with respect to assisted feeding techniques available for review by Licensing. The Licensing staff observed staff assisting 2 persons in care during the noon meal. The staff was standing (when they should have been sitting), utilizing a fast pace in assisting with feeding, resulting in the two persons in care needing to swallow food at a fast rate.
Corrective Action(s): Please ensure that records of any staff training are kept on file. In addition, please ensure that staff receive ongoing training in the preparation, delivery of food, nutrition, and assisted eating techniques as per Section 44(1)(b) and that PICs have sufficient time and assistance to eat safely and comfortably as per Section 63(5).
Date to be Corrected: Immediate. Submit a plan to licensing to ensure that all staff have been educated on assisted feeding techniques, including a review that will ensure staff understand the training; and auditing to ensure feeding is provided as required.
ADDITIONAL CCALA SECTIONS: 50050 - CCALA s.7(1)(b)(i) - A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care.
Observation: QA determined through information received from the Medical Director, that a person in care required a doctor ordered medication to be administered immediately, but the staff did not administer the medication as they did not want the person in care to be up and awake during the night. It was also determined by the Medical Director, that the medication was ordered from the pharmacy but the facility had the medication available in their contingency supply.
QA determined that a person in care did not receive timely treatment for a fracture. It was also identified that there was a lack of follow up, assessments, and documentation for this injury.
Corrective Action(s): Ensure that the community care facility is operated in a manner that will promote the health, safety and dignity of the person in care.
Date to be Corrected: Immediate
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