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: 3 out of 4 staff files that were reviewed did not have employee appraisals within the past year. Discussion with human resources determined that staff are to have them once each year.
Corrective Action(s): Please ensure that employees receive regular performance evaluations to ensure that the employee demonstrates the competence required for the their assigned duties.
Date to be Corrected: October 20, 2017
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 2 out of 3 resident's Medication Administration Records (MAR) found that the effectiveness of administered PRN's has not been recorded for any of them. Discussion with the nurse determined that staff is supposed to record these. The facility has E-MAR which is supposed to notify staff to record the effectiveness but that this function was not working properly and staff were not aware that it should be recorded.
Corrective Action(s): Please ensure that employees comply with the medication safety and advisory committee's policies and procedures for recording PRN effectiveness.
Date to be Corrected: October 13, 2017
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Review of policies and procedures and discussion with human resources determined that the policies and procedures have not been reviewed and/or revised since May 2016.
Corrective Action(s): Please ensure that policies and procedures are reviewed and revised, if necessary, at least once each year.
Date to be Corrected: October 20, 2017
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Review of the following food items were found to be expired or stored in an unsafe manor:
- emergency supplies water had expired in 2016.
- 2 expired canned items in the pantry.
- a hamburger patty left unopen in the freezer.
- 2 items not labelled or dated in the freezer.
Corrective Action(s): Please ensure that food is safely prepared and stored.
Date to be Corrected: October 13, 2017
NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Review of nutrition information found that there were no menu audits ensuring that resident's are offered 3 meals each day with each meal containing at least 3 food groups.
Corrective Action(s): Please ensure that the menu contains at least 3 food groups in each meal as described in Canada's Food Guide.
Date to be Corrected: October 20, 2017
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