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: A health and safety plan was put in place to ensure that wound care audits were being completed. Upon review of the wound care audits provided, it was determined that the audit system put in place is not effective
Corrective Action(s): Ensure that the health and safety plan put in place is maintained and monitored for effectiveness, until such time as you receive notification from Licensing that it can be removed or modified.
Date to be Corrected: Immediate. Review your submitted health and safety plan to ensure that it can be effectively implemented.
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: Review of documentation found that formal audits were being completed but were not effective in recognizing inconsistencies in multiple care systems, determining that the new formal audits are inadequate and ineffective.
Corrective Action(s): Ensure that there is effective regular monitoring of the community care facility and the care services provided to ensure that services meet all the requirements of the Community Care and Assisted Living Act (CCLA) and Residential Care Regulations (RCR).
Date to be Corrected: Immediate. Submit a new plan to licensing to review and update all audits and monitoring systems to evaluate gaps and ensure ongoing compliance in all areas.
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: Discussion with facility Leadership and reviews of staffing schedules determined that there continues to be challenges with staffing. Licensing and the QA Analyst continue to review the staffing schedules submitted by facility Leadership and the processes for when different staffing roles/lines have vacancies ex. sick staff.
Corrective Action(s): Ensure that staffing coverage is sufficient and organized to meet the care and supervision requirements of the persons in care.
Date to be Corrected: Immediate. Review the submitted staffing schedule to ensure staffing coverage is sufficient to meet the care and supervision needs of persons in care
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: Documentation was reviewed for 16 staff and determined that 7 staff did not have a valid First Aid certificate. It could not be determined from the documentation provided, if there was a system in place to ensure that a staff with a valid first aid certificate was working each shift.
Corrective Action(s): Ensure that persons in care at all time have immediate access to an employee who has a valid first aid certificate.
Date to be Corrected: Immediate. Please submit a plan that ensures there is a system in place to confirm that a staff with a valid first aid certificate is working each shift.
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 the MAR record determined that 3 persons in care were being administered medication 2 hours early, which is not within the guidelines outline in the facilities MSAC policies and procedures.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: Immediate. Review with staff the policies and procedures outlining medication administration time lines.
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 documentation confirmed an updated list of persons in care requiring tray service. However, further review found no documentation of an assessment by a medical practitioner, nurse practitioner, or dietician for the persons in care requiring tray service.
Corrective Action(s): Ensure that persons in care requiring room tray service are reassessed at least once every 30 days by either a medical practitioner, nurse practitioner, or a dietician.
Date to be Corrected: Immediate. Please submit a plan to ensure that all persons in care nutrition documentation is complete and includes a sustainable 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 9 care plans, activity of daily living (ADL), chart records, computer charting, wound care binders, restraint binders, and family binders, found that information was inconsistent or incomplete for all 9 care plans reviewed.
-New assessments were completed for all high risk concerns but were not thoroughly completed and all were missing information. ex. missing names, missing dates, missing follow up information.
-Old assessments were not removed from the paper charts and were with current treatment plans.
-Care plans and ADL's were not consistent and had conflicting information.
-Wound documentation was inconsistent with what was in the designated wound care binder and the care plan.
Corrective Action(s): 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: Review of 9 persons in care (PIC) care plans found the following:
-1 person in care had 2 wounds listed in their care plan but 3 wounds were listed in the wound care binder
-1 person in care had a wound picture that was not updated weekly, as per wound care policy
-3 persons in care with chewing and swallowing issues identified by facility leadership but 2 had assessments had no concerns noted for chewing or swallowing
-7 person in care ADL's did not match the care plans for falls interventions ex. falls mat, hip protectors, bed alarms were not listed.
-1 person in care did not have any purple dot identifier on their wheelchair
-1 person in care's turning frequency and pad checks noted on the care plan was not consistent with the information on the ADL
Corrective Action(s): Ensure that care plans are reviewed and modified if there is a substantial change in the circumstances of the person in care.
Date to be Corrected: April 10, 2020
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: Review of 9 care plans determined the following:
-one person in care had 3 different wound care plans for 1 wound
-one person in care with a wound required only a pad and the person in care had both a brief and a pad
-one person in care 2 different wounds on 1 wound assessment and treatment sheet
-one person in care had a 10 day gap of documentation when dressing was to be changed every 3 days
Corrective Action(s): Ensure that the care and supervision is consistent with the terms and conditions of the person in care's care plan.
Date to be Corrected: Immediate. Submit a new plan that includes immediate review of all care plans to ensure they are current and properly implemented.
RECORDS AND REPORTING: 39350 - RCR s.84(b) - 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: (b) the reason for the use of the restraint.
Observation: Review of restraint records found that there was no documentation for the reason for the use of restraint in 4 of 9 care plans.
Corrective Action(s): Ensure that restraint documentation is complete.
Date to be Corrected: April 10, 2020
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 and licensing have determined that the care being provided is inconsistent and that there continues to be concerns about appropriate care and staffing. Assessments are not accurate or complete and there is evidence that the monitoring of high risk care concerns is not effective .
Corrective Action(s): Ensure that the licensee must operate the community care facility in a manner that will promote the health, safety, and dignity of persons in care.
Date to be Corrected: Immediate.
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