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 facility was not able to provide evidence of medication room audits completed as per required timelines. The most recent medication room audit was dated May 2021, and the next most recent audit dated February 2020.
Corrective Action(s): Ensure all medication room audits are completed on a regular basis, as per required timelines.
Date to be Corrected: March 10, 2022
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(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: Six person in care's charts were reviewed, and one person in care's chart had no evidence of a written agreement with the medical practitioner, nurse practitioner or family/guardian to use restraints for the two restraints present. Facility informed they had identified one restraint as a repositioning tool when the restraint restricts the person's movement, thereby defining it as a restraint. The facility reports the second restraint is not being used, yet it is listed on the care plan of the person in care, and staff verified it is the wishes of the family to use this restraint, during inspection.
Corrective Action(s): Ensure all use of restraints have written agreements by a health care practitioner, and family/guardian.
Date to be Corrected: March 10, 2022
CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: Six person in care's care plans were reviewed, and found three person in care's care plans did not include encouragement of examination by a dental health professional at least once per year.
Corrective Action(s): Ensure all person in care's care plans include encouragement to have an examination by a dental health professional at least annually.
Date to be Corrected: March 10, 2022
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: A review of the medication systems showed one bottle of a medication with a person in care's personal label, and no pharmacy label.
Corrective Action(s): Ensure all medications being administered to person's in care are packaged by the designated pharmacist.
Date to be Corrected: February 25, 2022
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