PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Review of the hot water temperature found it to be 49.9 degrees Celsius.
Corrective Action(s): Please ensure that the water temperature does not exceed 49 degrees Celsius.
Date to be Corrected: Dec 5,2019
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 (CORRECTED DURING INSPECTION): Review of 1 PIC's dining table tray found that the table was dirty and the PIC was about to be served lunch on it. Staff corrected this when licensing pointed it out.
Corrective Action(s): Please ensure that tables are maintained in a safe and clean condition.
Date to be Corrected: Dec 5, 2019
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: 2 out of 10 person in care (PIC) closets has stuffed animals, clothing, and other items being stored on the floor. Of concern is that the floor would not get cleaned and sanitized.
Corrective Action(s): Please ensure that closet floors are maintained in a clean condition.
Date to be Corrected: Dec 19, 2019
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (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: 1 PIC's who have restraints did not have consent forms filled out, including consent from the medical or nurse practitioner.
Corrective Action(s): Please ensure that anyone who requires a restraint has authorization from the medical or nurse practitioner.
Date to be Corrected: Dec 1, 2019
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 following documentation found that employees are not implementing policies and procedures regarding the completion and accuracy of their documentation for PICs.
- Review of 4 different PRN medications given to 4 different PICs found that 3 of the medications did not have the results indicated.
Review of 6 PICs care plans found the following documents to be incomplete:
- 1 PIC's Flow Chart had at least 20 signatures not present. Their restraint monitoring record was also not signed on at least 6 days.
- Another PIC is at risk of elopement and their monitoring sheet was not signed at least 5 times.
- Another PIC's flowsheet was not signed at least 30 times.
- Another PIC who is at risk of elopement did not have their monitoring sheet signed on at least 10 days.
- The 5th PIC's flowsheet was not signed at least 40 times and their restraint monitoring sheet was not signed on at least 15 shifts.
5 out of 6 lifts being stored in the hallways did not have the locks on. Discussion with the DOC determined that the locks she be on when not in use.
Corrective Action(s): Ensure that policies and procedures regarding documentation are implemented by employees.
Date to be Corrected: Dec 5, 2019
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