PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31160 - RCR s.19(1)(c) - If a person in care requires monitoring, or a signalling device, to ensure that person's health and safety, a licensee must provide a monitoring system or signalling device that (c) will signal to employees that the person in care needs immediate assistance.
Observation: A call bell audit from Main North was reviewed for August 29 - September 4, 2016
Total number of call bells: 313
Total # of bells answered over the 10 minutes expected within the GDC policy: 78 (25%) This reflects a slight improvement overall from the previous follow up inspection where 28% of calls fell out of the range of GDC policy.
11 calls from 10-11 minutes
25 calls from 11-15 minutes
34 calls from 15-29 minutes
7 calls from 29-45 minutes
1 call over 45 minutes
The DOC reports that the care coordinators have not yet been reviewing the call bell audits at a regular frequency. This will be reviewed and discussed in the next few weeks.
Corrective Action(s): Ensure call bells are answered as per GDC policy
Date to be Corrected: September 30, 2016
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Cupboard and counter surfaces in many areas of the building are showing signs of wear or are broken. The Facilities Manager has put out a request for quotes to have the work completed.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair
Date to be Corrected: November 1, 2016
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31610 - RCR s.30(d) - A licensee must ensure that all bathrooms have (d) any other equipment that is necessary to protect the health, safety and dignity of the persons in care.
Observation: 1/2 tub room was observed to have extra carts stored in it.
Corrective Action(s): Ensure that all tub rooms are clear of clutter to allow PIC's the dignity and enjoyment of the bathing experience without clutter contained in the bathing area.
Date to be Corrected: September 30, 2016
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: GDC is on track for the December 31, 2016 date provided to CCFL to have all performance reviews up to date
Corrective Action(s): Ensure all employees have up to date performance evaluations.
Date to be Corrected: December 31, 2016
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 2 files with falls protocol found that 2/2 did not have neurovital signs recorded as required.
Corrective Action(s): Ensure all staff are following all GDC policies
Date to be Corrected: September 30,2016
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: The quality assurance team continues to work on this, and is on track with the completion date as previously provided to CCFL of December 31, 2016
Corrective Action(s): Ensure all PIC files have evidence of compliance with the province's immunization and TB programs
Date to be Corrected: December 31, 2016
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