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 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: (REPEAT CONTRAVENTION) A review of 3 staff files indicated that the performance appraisals are not current. The staffing checklist on the computer indicated that the next evaluation due for a staff was in 2018. The manager confirmed that facility policy states that staff appraisals are completed annually for the site and would have a plan going forward to address this.
Corrective Action(s): Ensure performance appraisals are completed regularly.
Date to be Corrected: January 2, 2022
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 5 person in cares medication administration records indicated that 5 regular medications had not been signed for the month of November. The manager confirms that the medications were given and that the staff had forgotten to sign the MARS. The manager confirms the facility will have a process in place to audit the MARS going forward.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: January 2, 2022
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: 2 out of 5 persons in care was observed with a lap belt. As a lap belt is classified as a restraint, it would need to be reviewed by a medical practitioner. There was no documentation found in the person in cares care plan to confirm this review had taken place. Further review of the sites restraint policy directed that the restraint must be reviewed by the medical practitioner and this would be a contravention to section RCR 85(1)(d).
Corrective Action(s): Ensure there is an agreement to the use of the restraint given in writing by the medical practitioner or nurse practitioner responsible for the health of the person in care.
Date to be Corrected: January 2, 2022
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(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 5 out of 5 persons in care determined that 1 PIC's weight had not been taken in the month of November and no documentation provided to explain why the weight was missing. Further discussion with the manager determined that the staff had been off on vacation.
Corrective Action(s): A licensee who provides a type of care must ensure that weights are taken at least once a month or provide a reason why the weight could not be obtained.
Date to be Corrected: January 2, 2022
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