PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: Review of the storage areas found that there was no regular schedule for cleaning storage shelves that stored continence products that have been removed from their packaging and placed directly on the storage shelves.
Inspection of one spa room found that the door was left ajar and accessible to persons in care.
Corrective Action(s): Ensure that all products are stored and maintained in a safe and clean condition.
Date to be Corrected: November 30, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Review of one PIC's room found that there were multiple food items stored in the room that were not labelled or did not have any expiry dates.
Corrective Action(s): Ensure that a
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: Review of the medication administration determined that the administering staff was not securing the medication cart when the cart was out of view. Discussion with the DOC determined that the facility would expect the staff to secure the medications when away from the medication cart.
Corrective Action(s): Ensure that the medications in the community care facility are safely and securely stored.
Date to be Corrected: November 30, 2018
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: Review of the employee records and discussion with the DOC determined that the performance reviews for all staff is in the process of being completed.
Corrective Action(s): Ensure that the performance of each employee is reviewed regularly to ensure that the employee continues to meet the requirements of this regulation.
Date to be Corrected: November 30, 2018
POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: Discussion with the DOC and ED determined that the policies and procedures were currently in the process of being updated and revised. Review of the current policies and procedures determined that they were outdated and some policies that are required were not available.
Corrective Action(s): Ensure that there are written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care (PIC).
Date to be Corrected: November 30, 2018
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: Review of the wound care for one PIC determined that the care plan wound monitoring documentation was not completed and that staff did not follow the facility policy for wound care.
Corrective Action(s): Ensure that policies are implemented by employees.
Date to be Corrected: November 30, 2018
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 (CORRECTED DURING INSPECTION): Review of one PIC's care plan determined that the regular monitoring for illegal substances/alcohol that is specifically outlined for one PIC was not completed on the first day of the inspection. Further review could not confirm if the monitoring was occurring regularly as there was no documentation to support the monitoring.
Corrective Action(s): Ensure that the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Date to be Corrected: CORRECTED DURING INSPECTION
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 one PIC's care plan found that one PIC's wound care plan did not reflect that the PIC's wound had resolved. Documentation was still being completed for daily wound care dressing that was not occurring.
Corrective Action(s): Ensure that each care plan is reviewed and if necessary, modified if there is a substantial change in the circumstances of the person in care.
Date to be Corrected: November 30, 2018
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: Review of the PIC's weights for 6 PIC's found that monthly weights were missing at least one weight and there documentation as to why the weight was missing.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: November 30, 2018
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