LICENSING: 30020 - RCR s.8(2)(a)(i) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (i) plans for the change.
Observation (CORRECTED DURING INSPECTION): During the first day of inspection, maintenance workers were present and working on the main north deck. No safety plan had been provided, and no notification was given to CCFL about work being completed. The door to the area was locked so the area was inaccessible to PIC’s.
Corrective Action(s): Ensure that all licensing is notified of all renovations to be completed and a health and safety plan is submitted.
Date to be Corrected: Corrected on Inspection
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 physical facility, cleanliness, staff files, care plans and documentation indicate gaps in the self-monitoring system. This is a repeat contravention from the 2017 and 2018 inspections.
Corrective Action(s): Ensure that regular audits are created and completed, and that the self monitoring of both physical facility and care services are completed and effective.
Date to be Corrected: September 15, 2019
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, the LO's noted that 2/6 of bed alarms inspected were not working.
In the SCU the common area bathroom has a call bell that does not work
This is a repeat contravention from the 2018 routine inspection.
Corrective Action(s): Ensure that all monitoring devices for PIC's are in good working order and signal assistance as required.
Date to be Corrected: May 31st 2019
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: On inspection the LO's noted:
- One room had an oxygen tank and mask for a PIC. The mask had a film of dirt on it. No cleaning schedule for the mask could be found.
- 3/8 of the falls mats inspected had staining
- In the SCU, chairs in the lounge area and hallways had fabric seats and backs with staining or worn fabric. Fabric chairs make in common areas are difficult to sanitize effectively
- A wheelchair in the common hallway in the SCU had a dirty seat, and the arm fabric was split.
Corrective Action(s): Ensure that all furniture and equipment for use by PIC's is maintained in a safe and clean condition
Date to be Corrected: June 30, 2019
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: LO's noted on inspection:
- 2 broken closet doors were found in MN out of 16 rooms checked on all units
- 1 broken dresser drawer was found in MN out of 16 rooms checked on all units
- MN west stairwell light cover broken
- Wall damages to corners if the dining area main north and lower north – paint chipped on base boards and walls
- MN broken wooden shelf in the food service cupboard
- MN Wall damages where lifts are stored
- Nursing station counter in lower north is worn to wood and not cleanable
- LN Counter damage behind sink in medication room – rotting and lifting
- 3/12 bedrooms had wear down to the metal on the corners, staff reported that there was a plan to purchase more corner guards
- A hallway in MS had a corner railing piece missing, making it difficult to sanitize
- MS hallway had chipped paint
- The MS nurses station swing door to enter and counter surface was worn down to bare wood making sanitization difficult
- SCU the common area bathroom has a hole in the door that one can see right through, and no lock on the door.
Corrective Action(s): Ensure the rooms and common areas are maintained in a good state of repair.
Date to be Corrected: July 15, 2019
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:
- In the SCU – a maintenance cart was in the hallway unattended, with a drill, screwdrivers and screws
- The floor in the SCU had visible dirt in the common hallway.
- There is storage of carts in the SCU tub room by the bathtub as PIC’s only use showers on the SCU this area is very cluttered and would not provide an appealing bathing space for PIC's
- Evidence of baits for ants, although no documentation was available for when the baiting began
- Rat trap observed in tub room no documentation available for how long and when trap was installed, and monitoring
- Window sills dusty and dirty in the dining area main north
- Broken drawers and garbage stored in the eating area of main north
- Food service cupboard was dirty and had food crumbs and garbage in it MN
- Tub brushes stored on the floor
- Mops stored on the floor MN
Corrective Action(s): Ensure all areas are maintained in a safe and clean condition.
Date to be Corrected: June 30, 2019
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: Cleaning chemicals were found in the tub room stored on the floor and unsecured.
This is a repeat contravention from the 2018 routine inspection.
Corrective Action(s): Ensure that all chemicals are safely and securely stored
Date to be Corrected: June 1, 2019
STAFFING: 32040 - RCR s.37(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: Review of 9 contracted and site staff files found that:
1/3 GDC staff did not have first aid. This staff is recreation and takes PIC’s out on outings
1/3 GDC staff did not have food safe and the staff member does handle food and assist with feeding
1/6 contracted staff files did not have an orientation sheet completed and it was confirmed the staff member has completed orientation and worked shifts.
Corrective Action(s): Ensure that all positions that require first aid have evidence to show that this training is current
Date to be Corrected: August 1, 2019
STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: Review of 9 staff files from contracted and GDC staff found that:
- 2/3 GDC staff did not have an annual performance evaluation policy as per GDC policy. One staff was hired in 2015 and did not have any performance evaluations in the file, One was last completed over two years ago in 2017.
- 2/6 contracted staff files had not completed or signed the policy sign off form that is included with the evaluation form.
This is a repeat contravention from the 2017 and 2018 routine inspection.
Corrective Action(s): Ensure that evaluations are completed as per GDC policy and are fully completed
Date to be Corrected: November 1, 2019
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: On inspection the LO noted:
- MN - Narcotic count missed for 2/12 days
- MN - PRN response not documented on E-MAR for 4 PRN administrations out of 8 checked
- No temperature sheets available for main north medication room fridge indicating temperature is not recorded or checked at all
- Out of 8 medications reviewed that were kept in the fridge in the MS med fridge 4/8 were medications from PIC’s no longer at the site.
- SCU 3/4 medications in the fridge belonged to discharged PIC’s
Corrective Action(s): Ensure that employees comply with medication policies
Date to be Corrected: June 15, 2019
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: On inspection and review LO's noted:
- 1/5 PIC files was missing an aggressive indicator assessment from admission
- 1/5 PIC files had two skin assessments showing on PCC but both were blank, no braden scale assessment was completed and the care plan indicated a risk of skin breakdown
- On review of PIC’s weights on PCC, it was noted that one PIC had several alerts on PCC from the past 6 months that identified a shift of 3.5% in weight per month. Staff stated that the expectation on these PCC alerts for weight change is that a referral to the dietician must be completed. There was no notes that a referral was completed and the RD confirmed she had not received one but she had identified and addressed the weight loss in her own annual care conference review.
- Fridge temps not documented for 6 days prior to inspection in the servery area MN as required by temp monitoring system in place
- PCC shows approx. 15 falls from MN from January 2019 until April 2019 that have not been reviewed by the CC for follow up as required.
- 1/8 falls follow up documentation reviewed did not have complete neurovitals completed as per falls policy on MS
- 5/5 Falls follow up did not have evidence of the Post Fall Huddle or Reassessment/Follow Up portion of the Falls Policy
- An audit of POC found 15/25 PIC's on MS/SCU did not have documentation completed as required. During the two days of the inspection POC was reviewed the first day at 12:30 and the second day at 13:00. The audit showed several items from 0700, and 1100 and 1200 had not been documented as complete such as toileting, mouth care, and Q2H visual checks. An audit of the day before the inspection shows all documentation as complete for all PIC’s in both MS and SCU. From these audits it appears that staff are not documenting at the time of providing care as required. A similar audit was conducted on POC on MN of 3 PIC's documentation and 3/3 had missing documentation on the first day of inspection.
Not following documentation policy is a repeat contravention from the 2018 inspection.
Corrective Action(s): Ensure that policies are implemented by employees
Date to be Corrected: June 30, 2019
CARE AND/OR SUPERVISION: 34080 - RCR s.49(3) - A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.
Observation: Review of 5 PIC files found that 1/5 was missing an elopement risk assessment on admission
Corrective Action(s): Ensure that all PIC's are assessed for elopement risk on admission
Date to be Corrected: June 15, 2019
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 charts for oral care for 15 PIC's on different units found that at 1300 on the first day of the inspection for 12/15 PIC's oral care was not documented as completed although it is scheduled for 0700.
This is a repeat contravention from the 2018 routine inspection.
Corrective Action(s): Ensure that oral care is completed as required
Date to be Corrected: September 1, 2019
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 care plans found that 1/8 was missing a recreation care plan.
This is a repeat contravention from the 2018 routine inspection.
Corrective Action(s): Ensure that all PIC's have a recreation care plan
Date to be Corrected: June 15, 2019
CARE AND/OR SUPERVISION: 34670 - RCR s.81(3)(e)(i) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (i) an assessment of the nature of the risk of falling presented by the person in care.
Observation: Review of PIC files found that 1/5 was missing a falls risk assessment
Corrective Action(s): Ensure that all PIC's have a falls risk assessment completed.
Date to be Corrected: July 15, 2019
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: On review of 6 care plans, 1/6 was found to be updated on PCC but a new copy was not printed for the care plan binder available for staff. The care plan and ADL in the binder did not include any information on nutrition/diet although on PCC the information was complete
This is a repeat contravention from the 2018 routine inspection.
Corrective Action(s): Ensure that the current care plan with all of the current information is available for all staff
Date to be Corrected: July 15, 2019
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Review of 8 care plans found that 1/8 had not updated within one year. The PCC annual review date was overdue.
Corrective Action(s): Ensure all care plans are reviewed every 12 months and updated as required
Date to be Corrected: September 1, 2019
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: Review of 5 wound care plans found that 2/5 did not have documentation to show the treatment had been followed as specified. One plan was missing 2/9 days and the other had 3/9 days missing.
Corrective Action(s): Ensure that all care plans are followed as required.
Date to be Corrected: July 15, 2019
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: Review of 11 PIC’s records 3/11 did not include immunization records
Corrective Action(s): Ensure that all admissions have evidence of compliance with the province's immunization program
Date to be Corrected: August 1, 2019
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: On inspection the LO's found:
- Barrier cream not labeled in 6 rooms and 2 tub rooms LN and MN
- Conditioner had different PIC's name on it MN
- Deodorant in the tub room had no PIC names MN
- Nail clippers in 3 tub rooms had no PIC names LN MN
- Tooth brush kept in water in 1 bedroom
- 1 tooth brush holder was dirty bedroom
- Face shavers and razors not labelled in 1 tub room LN
Corrective Action(s): Ensure a system is in place to eliminate the possibility of cross contamination of hygiene products, and ensure that all hygiene products are in safe and clean condition.
Date to be Corrected: August 1, 2019
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 PIC weight records found that 2/8 PIC’s had missing weights from the past 12 months (both were missing 1/12 months)
Corrective Action(s): Ensure all weight records are complete. If there is a reason the PIC was not weight, indicate it in the records.
Date to be Corrected: August 1, 2019
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