POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(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: One PIC who requires the use of a restraint, did not have an agreement signed by their medical practitioner.
Corrective Action(s): Please ensure you have a written agreement from either the medical practitioner or nurse practitioner if a restraint is required.
Date to be Corrected: July 6, 2022
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: The Licensees policy requires staff to document on the medication administration record (MAR) the effectiveness of medication when administered as needed (PRN) to persons in care (PIC). Four MARs were reviewed. One PIC was administered a PRN medication by staff and on four occasions staff did not document the effectiveness of the medication as required.
Corrective Action(s): Please ensure staff implement the policy and document the effectiveness of PRN medications as required.
Date to be Corrected: July 6, 2022
RECORDS AND REPORTING: 39390 - RCR s.84(f) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (f) employee compliance with the requirements of Division 5 [Use of Restraints] of Part 5.
Observation: A person in care requires the use of a restraint. In review of the PICs care plan it was determined that it did not include evidence of compliance with all the requirements of Division 5 [Use of Restraints] of Part 5 of the RCR.
Corrective Action(s): Please ensure if a PIC is restrained, their care plan demonstrates compliance with the required regulations.
Date to be Corrected: July 6, 2022
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: The audits for the four week menu currently in use were incomplete, missing the 2nd pages for each one.
Corrective Action(s): Please ensure menu audits are complete.
Date to be Corrected: July 6, 2022
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