LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: Regular monitoring and audits of the facility will ensure that systems are functioning the way they are intended. Numerous contraventions in the areas of cleanliness, staffing files, care plans and documentation indicate gaps in the self-monitoring system. This is a repeat contravention from the 2017 routine inspection.
Corrective Action(s): Ensure that regular audits and the self-monitoring of the physical facility and care are services are completed and effective. Please provide an improved audit plan for the areas identified in this inspection.
Date to be Corrected: June 30, 2018
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: On inspection of 4 PIC rooms that require bed alarms according to their care plan found that 2/4 did not have the bed alarms plugged in. 1/2 was not working correctly when plugged in the other 1/2 was corrected on inspection and working properly.
Corrective Action(s): Ensure that all monitoring devices signal to employees the need for assistance
Date to be Corrected: May 15th 2018
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: On inspection the LO noted:
- the greenhouse/gazebo outside the main foyer area has broken panels, and wood planks leaning to support the roof structure. As this area appeared quite unsafe - at the request of the LO GDC staff implemented a CCFL approved health and safety plan that was in place by the third day of the inspection
- broken planter pots with sharp edges by the greenhouse/gazebo area, broken planks on the wooden planter pots
- broken tile and pieces of missing tile around the bottom of the fireplace in the dining room of MN
- MS med room the edging on the wall was worn down to the metal, MS tub room wall edging down to the metal and some holes in the wall where paint had chipped off, several PIC main bedroom door frames down to the metal, several holes in the wall of the small lounge on MS, PIC bedroom wallpaper peeling and a broken electrical outlet, MS staff area paint worn off down to the wood surface on the counters and door. On MN cracks in the linoleum down to the cement on the floor. Effective sanitization is hindered when the surface is compromised.
- 10/19 of PIC bedrooms inspected found closet doors that were either off the tracking system, sticky, warped or bent making it difficult to open
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair
Date to be Corrected: Please submit an action plan for all items with proposed dates of completion. All items to be remedied by August 31, 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: On inspection the LO's noted:
- the outside area by the main foyer had a large concrete planter filled with sitting water that was accessible to PIC's (not accessible by day 3 of the inspection)
- MS east hallway bathroom toilet has brown caulking around the bottom
- MS tub room had dirty cleaning brushes on the floor in the shower area with pooling dirty water, nail scissors on the floor, blue edging for the tub was falling off and a brown sticky surface was exposed underneath
- several stained falls mats in PIC bedrooms
- one PIC bedroom had a soiled incontinence pad hanging halfway out of the garbage can onto the floor
- the toilet in one of the bedrooms was not flushed by staff and had urine and feces in it. The ADL stated that the PIC has a 1 person assist to use the washroom
- sanitization wipes and incontinence pads left between the handrail and the wall in the hallway
- In MN tub room on the counter or in the drawer there were: razors, nail clippers and deodorant with no labelling as to who they belonged to and remnants of feces on the toilet seat
- In LN tub room the following were on the counter or in a drawer: a hair brush, several nail clippers, razors, nail scissors and dried urine on the toilet seat
- LN smoking room there were several cigarette butts on the floor (corrected on inspection)
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition
Date to be Corrected: May 31, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: On inspection the LO's noted:
- on MN a cart with 3 personal care cleaning sprays that had warnings on the bottle regarding ingesting and getting in eyes was found unattended in the hallway outside of bedrooms, there was also an open garbage bag on the cart that smelled of urine
- on MN a maintenance cart was left unattended, which contained tools in the accessible cupboards and screwdrivers lying out on an open shelf
Corrective Action(s): Ensure that there is secure, safe, adequate storage for all hazardous or potentially dangerous materials
Date to be Corrected: April 15, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31890 - CCALA s.7(1)(b)(i) - A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Observation (CORRECTED DURING INSPECTION): During the inspection the LO and a staff member accessed the outside area through the town hall room, that has doors open to the main foyer. These doors are accessible to all PIC's. After inspection of the outside area, the LO and staff member went to return through the same doors and they do not open from the outside. The LO and staff member were unable to find any entrance for PIC's to get back inside once getting outside to this area. There is a main door that staff can use a swipe card to open. As it was very cold outside, there was a risk to PIC's getting stuck outside. An immediate health and safety plan to resolve this issue was requested by the LO and implemented by day 3 of the inspection.
Corrective Action(s): Ensure that the physical site does not include any risks to the safety of PIC's.
Date to be Corrected: Corrected. Please submit long term plan with the action plan to CCFL.
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: A mixture of both contracted and site employed staff files were reviewed, and 1/12 of the site employed staff files did not include evidence of a current criminal record check. This is a repeat contravention from the 2017 routine inspection.
Corrective Action(s): Ensure that all employee files include evidence of a current criminal record check
Date to be Corrected: July 15, 2018
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: A mix of both contracted and site employed staff files were reviewed and 2/6 contracted staff and 4/6 site employed staff did not show evidence of an employee appraisal within the past year. GDC policy states that employee appraisals are to be completed annually. 2/6 of the overdue site employed staff appraisals were last completed in 2011. This is a repeated contravention from the 2016 and 2017 routine inspections.
Corrective Action(s): Ensure that all employees have appraisals completed annually as per GDC policy
Date to be Corrected: October 31, 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 Activity Daily Log - Record of Care for 5 PIC's for December 2017 and January 2018 found that:
- one PIC had someone else's form in his chart
- 2x daily wash / peri care was not signed
- 4x where wetness was not signed
- 1x where wandergaurd check was not signed
- 4x where a personal safety check was not signed
- 4x where meals consumed was not signed
- 7x where fluids consumed was not signed
- 3 days in a row where repositioning was not signed
- 23x where repositioning was signed off for one PIC who did not require it
- From December 18th 2017 - January 7th 2018 only one "B" signed to indicate the PIC had a bath when weekly baths/showers are the expectation
- Hip protectors signed off as "R" which indicates refused, when the PIC did not have hip protectors
- 2/7 instances where the binder used by RCA's did not have the most up to date care plan
- One instance where "B" for bath was documented for one PIC 3/4 days so far that current month (March 2018) and one of the dates twice in one day. Discussion with staff found that that PIC did not have 4 baths in the first 4 days of March 2018
The policies on documentation for GDC require complete accurate documentation.
A review of 6 PIC's that had recent falls found that 6/6 had a falls risk assessment and 6/6 had complete neuro vital and progress note records for the falls. 5/6 had information about falls prevention in their annual care conferences but 0/6 had the falls follow up form in their binder as required in GDC policy and 1/6 had some information on interventions tried but declined/unsuccessful as required in policy. The policy also outlines GDC having a Falls Team that regularly evaluated falls at GDC, conversation with staff found that this is still not currently in place. This is a repeat contravention from the 2017 routine inspection.
Corrective Action(s): Ensure that documentation is complete and accurate as required in GDC policy
Date to be Corrected: June 30, 2018
CARE AND/OR SUPERVISION: 34150 - RCR s.53 - A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of all persons in care, ensure respect for the personal privacy of each person in care, including the privacy of each person in care's bedroom, belongings and storage area.
Observation (CORRECTED DURING INSPECTION): Inspection of a hallway bathroom on MS east found an incontinent spray cleanser and barrier ointment for toileting care on the counter including two different PIC names. Removed by staff on inspection.
Corrective Action(s): Ensure that the privacy of each PIC's personal care items is maintained.
Date to be Corrected: April 30, 2018
CARE AND/OR SUPERVISION: 34190 - RCR s.54(3)(b)(i) - A licensee must (b) assist persons in care to (i) maintain daily oral health.
Observation: Review of the Activity Daily Log - Record of Care for 5 PIC's for 2 months found that 3/5 PIC's had blank spots on their chart with no indication as to if mouth care was completed. Of the 3, one had 3 days missed one had 2 days missed and one had 1 day missed. All of the 5 PIC's had documented refusals of assistance with mouth care sometime in the 2 months audited.
Corrective Action(s): Ensure that all PIC's have assistance to maintain daily oral health.
Date to be Corrected: April 30, 2018
CARE AND/OR SUPERVISION: 34630 - RCR s.81(3)(b) - A care plan must include all of the following: (b) an oral health care plan.
Observation: Review of 7 PIC care plans found that 1/7 did not include an oral health care plan
Corrective Action(s): Please ensure that all PIC's have an oral health care plan
Date to be Corrected: June 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: Of 7 care plans reviewed 1/7 did not include information on a recreation care plan. This is a repeat contravention from the 2017 routine inspection.
Corrective Action(s): Ensure all PIC's have a recreation care plan
Date to be Corrected: June 1, 2018
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 4 care plans for PIC's identified with wounds, found that 1/4 had an identified ulcer on the care plan but no wound care documentation for treatment. The PIC also had not had an updated Braden Scale Assessment since Sept 2016, and this assessment is required by GDC annually for any PIC identified to be at risk for skin breakdown. This is a repeat contravention from the 2017 routine inspection.
Corrective Action(s): Ensure that all PIC's with wounds have documented wound care treatment, and assessments completed as required.
Date to be Corrected: April 30, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: A mix of both contracted and site employed staff files were reviewed (6/6 = 12 total) and 1/6 of the site employed staff files did not include evidence of compliance with the province's TB control program. This is a repeat contravention from the 2017 routine inspection.
Corrective Action(s): Ensure all employee files include evidence of compliance with the province's immunization and TB control programs
Date to be Corrected: July 15, 2018
MEDICATION: 36080 - RCR s.69(1)(b) - A licensee must ensure that a pharmacist (b) records all medications on the person in care's medication administration record.
Observation: Review of 10 PIC MAR records found that 3/10 had hand written medication information. This is a repeat contravention from the 2016 and 2017 routine inspections.
Corrective Action(s): Ensure that the pharmacy records all medications on the MAR
Date to be Corrected: April 30, 2018
MEDICATION: 36160 - RCR s.72(a) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (a) the person in care is no longer taking the medication.
Observation: Inspection of two medication fridges on two units found that the one on MS had 5/18 medications that were for PIC's that were no longer at the site.
Corrective Action(s): Ensure that all medications are returned to the pharmacy when no longer required
Date to be Corrected: May 15, 2018
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