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 9 staff files, found that 3 casual staff did not have completed annual performance reviews as outlined in the facility policy for employee evaluations.
Corrective Action(s): Ensure that all employee's performance is reviewed regularly as outlined in the facility policy.
Date to be Corrected: January 22, 2017
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 (CORRECTED DURING INSPECTION): Review of the Medication Administration Records (MAR) for 1 of 4 persons in care (PIC); determined that the PRN's records were not complete and the back of the MAR sheet did not provide for an area to record the following: PRN date administered; PRN reason; PRN results; etc. The facility MSAC policy requires this information to be recorded and it was not captured.
Corrective Action(s): Ensure that receipt of the new monthly MAR sheets have an area to record the PRN's reason and results, and that this is completed as outlined in the facilities MSAC policies.
Date to be Corrected: CORRECTED DURING INSPECTION.
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 1 of 4 care plans found that one PIC was missing a recorded weight for November 2017.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: January 22, 2017
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