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: Review of the 2 emergency preparedness bags found that all of the water and food had expired in April of 2012. Discussion with the manager determined that the facility gets the bags from their head office and that the bags are sealed with zip ties when they arrive and that staff does not check the contents; the manager had to cut the ties in order to show licensing the items in the bag. The manager stated that there is additional water that would be taken, although it had also expired and that staff would also take food from the pantry.
The following items were found in the fridges and freezers to not be labeled and dated:
-4 packages of waffles, cranberry sauce, 2 eggs, and an unknown frozen item.
Corrective Action(s): Ensure that there is a self monitoring component
Date to be Corrected: October 14, 2016
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: Following physical facility items were noticed during the inspection:
- The flooring around the dining room table is showing considerable wear from the chairs scratching against it. Conversation with the manager found that they have put a request in for the repair to be completed, but have not found out when this might happen. This was also contravened on last years routine inspection (NTJN-A3GPJH).
- The wall by a swivel chair in the living room is scratched from the chair moving back and forth against it. The manager said that the wall had been painted, but that the wrong type of paint was used which has caused the paint to scratch off quicker.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: November 4, 2016
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31830 - RCR s.36(2) - If necessary to protect the health or safety of persons in care, a licensee must ensure that the outside activity area is secured by a fence or other means.
Observation: One of the gates in the backyard is partly unhinged; one of the brackets has come off. The manager is aware of the issue and has put a request in to have it fixed. One of the residents at this facility has exit seeking behaviors and has tried and left the facility through other exits and is at risk of discovering this gate is broken as they do use the backyard.
Corrective Action(s): Ensure there is a secured fence surrounding the outside activity area.
Date to be Corrected: October 21, 2016
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: Review of 3 out of 4 Persons in Care (PIC) Medication Administration Record (MAR) found the following:
- 1 PIC's MAR had 1 initial missing for a PRN that was administered as it was recorded on the back of the MAR.
- Another PIC's MAR had an initial missing for a medication that had been administered and 1 PRN result not recorded.
- Another PIC's MAR had 2 initials missing for medications which were administered.
Corrective Action(s): Please ensure that employees comply with the Medication Safety and Advisory Committee policies and procedures.
Date to be Corrected: October 11, 2016
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: There were no meeting minutes from the Medication Safety and Advisory Committee's (MSAC) meetings. Discussion with the manager determined that they meet, but there are no formal minutes available to support this.
Corrective Action(s): Please ensure that MSAC establishes and reviews policies and procedures in regards to the safe and effective storage, handling, and administration of PICs' medications and that there is evidence to support this.
Date to be Corrected: November 4, 2016
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: 3 PICs care plans were reviewed and found that they did not have evidence of screening for tuberculosis.
Corrective Action(s): Please ensure that each PIC complies with the Province's immunization and tuberculosis control programs.
Date to be Corrected: November 4, 2016
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