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: Inspection of the facility found that on all three days of the inspection, it was noted that the tub rooms, soiled laundry rooms, clean laundry rooms, and storage rooms were left unlocked and accessible to persons in care. It was noted that signs were posted on all doors and stated that the doors must remain closed and locked. This was identified to the staff on the first day of inspection but doors to these rooms were still found to be open and unloced on all three days of the inspection.
Inspection of the oxygen tank storage area found 4 empty oxygen tanks that were freestanding and not secured or in a cart.
Inspection of one storage room found that incontinence products had been removed from the packaging and were not hygienically stored.
Inspection of one of the units found one large door leading to the loading dock was missing.
Corrective Action(s): Ensure that all room and common areas are maintained in a safe and clean condition.
Date to be Corrected: October 1, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31850 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation (CORRECTED DURING INSPECTION): Inspection of one dining room found that a menu was not displayed but the daily meal was written on a white board..
Corrective Action(s): Ensure that a menu is displayed in a prominent place in each dining area for each weekly period.
Date to be Corrected: CORRECTED DURING INSPECTION
STAFFING: 32260 - RCR s.44(1)(b) - A licensee must ensure that employees responsible for the preparation and delivery of food (b) receive ongoing education respecting the preparation and delivery of food, nutrition and, if required, assisted eating techniques.
Observation: Review of the dining room service observed inapropriate feeding techniques and discussion with the Clinical Nurse Educator (CNE) determined that currently there is no on-going education except for new hires. The facility has plans to initiate regular in-services starting in September 2018.
Corrective Action(s): Ensure that all employees responsible for the preparation and deliver of food received ongoing education respecting the preparation and deliver of food, nutrition and assisted eating techniques.
Date to be Corrected: October 1, 2018
CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: Review of 3 of 6 care plans found no recreation or leisure plan. It could not be determined what form was the recreation assessment as different forms were found but not consistently in all care plans.
Corrective Action(s): Ensure that care plans are complete and contain a recreation/leisure plan.
Date to be Corrected: October 1, 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: Review of 12 care plans found the following:
-one PIC's diet captured in the care plan was not consistent with diet documentation on the ADL.
-one PIC did not have any diet information documented on their ADL but were identified with the coloured dot system, that they were diabetic. It was also noted that this PIC's diet was not capture on the dining room diet list.
-3 PIC's flow sheets had documentation missing for a complete staff shift and it could not be determined if the information was missing or not applicable to the persons in care
Corrective Action(s): Ensure that the implementation of each care plan is regularly monitored to ensure proper implementation.
Date to be Corrected: October 1, 2018
CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Observation: Review of the person in care weights found that weights were not obtained for some PIC's. Discussion with staff determined that two PIC's refused to be weighed and that is why their weight was not captured.
Corrective Action(s): Ensure that if a person in care refuses or is unable to be weighed that the licensee must record in the nutrition plan of the person in care the reason why the person in care was no weighed.
Date to be Corrected: October 1, 2018
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: A review of 4 of 10 care plans had incomplete documentation and it could not be determined if the PIC's comply with the Province's immunization and tuberculosis control programs.
Corrective Action(s): Ensure that all persons in care records are complete.
Date to be Corrected: October 1, 2018
PROGRAM: 38010 - RCR s.55(1)(a)(i) - A licensee, other than a licensee who provides a type of care described as Hospice, must (a) provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities (i) suitable to the needs of the persons in care.
Observation: Review of 3 of 6 care plans found that 3 persons have not participated in any recreational programs since admission over the last three years.
Corrective Action(s): Ensure that the facility provided an ongoing planned recreation program suitable to the needs of all persons in care.
Date to be Corrected: October 1, 2018
RECORDS AND REPORTING: 39300 - RCR s.80(2) - Anything that must be recorded in a care plan under this regulation must be recorded in the short term care plan until a care plan is developed.
Observation: Review of 2 of 6 short term care plans found the following:
-one PIC short term care plan only documented a falls assessment
-one PIC short term care plan only documented nutrition needs and Activities of Daily Living (ADL).
Corrective Action(s): Ensure that short term care plans are complete.
Date to be Corrected: October 1, 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 all four units determined that weights are documented on paper and then inputted on each unit. Review of all units found that weights were missing on the paper with no reason given why weight was not obtained (ex. refusal). Review of the weights on the computer system found that monthly weights were not inputted on the computer ex. one unit was missing June and July weights, one unit was missing July, some PIC's had no paper weight documented and no computer weight documented.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: October 1, 2018
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