| Menno Place - Menno Hospital - Complaint Information |
| General Details | |
|---|---|
| Facility Type | Residential Care (Hospital Act) - 400 |
| Investigation Completed | May 15, 2023 |
| Reason for Investigation | - Policies and procedures - Care and supervision - Medication - Nutrition and food services |
| Report of Findings |
|---|
| Licensing received a complaint on December 1st, 2022, regarding Care and Supervision, Physical Facility, Medication, Policies and Procedures, and Records and Reporting. The following information was provided: · Inappropriate medication practices · Medical records were not maintained as required · Inaccurate or incomplete information was provided to health professionals · Required notifications were not provided to the family of the person in care (PIC) · Care and Supervision was not provided according to facility policies · Furniture and equipment used by the PIC was not maintained in a good state of repair · The PIC was not treated in a manner that promoted their health, safety, and, dignity · Respect was not maintained for the PIC’s personal belongings or privacy · The PIC was not assisted with accessing medical services in response to changes in their condition · Staff did not have the appropriate skills or training · Care was not provided according to the care plan in the areas of medical treatment, activities of daily living, and nutrition · The care plan was not directed by the PIC and their family All concerns within the licensing mandate were fully investigated. Evidence was collected through facility records. Licensing determined the following sections of legislation were not met: - Residential Care Regulation (RCR) Section 85(1)(a) - Policies and procedures - RCR Section 85(1)(d) - Policies and procedures - RCR Section 68(4) - Medication safety and advisory committee |
| Substantiated Contraventions: Evidence for this summary report is based on a combination of the Licensing Officer’s observations, a review of facility records and information provided by the facility staff at the time of the investigation. |
| Observed Violations/Contraventions: A summary of the violations found during the complaint investigation are listed below. |
| Code | Category/Description |
|---|---|
| 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: Staff failed to follow MSAC policies regarding medication administration and documentation in greater than seventy-five instances during a two-month period. Corrective action: Ensure employees comply with policies and procedure of the medication safety and advisory commitee. |
| 33220 - RCR s.85(1)(a) | A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care. Observation: A procedure was not in place to guide staff's response when a PIC had not return to the facility. Corrective action: Ensure there are written policies and procedures to guide staff. |
| 33280 - RCR s.85(1)(d) | A licensee must do all of the following: (d) ensure that policies are implemented by employees. Observation: Staff did not implement facility policies regarding medical monitoring and providing updates to the doctor, including after a substantial change in the PIC’s condition. Corrective action: Ensure policies and procedures are implemented by employees |
| Actions Required by Licensee/Operator | |
|---|---|
| - Licensee has addressed some contraventions. Corrective action plan required to be submitted. |
| Action Required by Licensing Officer or Medical Health Officer | |
|---|---|
| - Review and monitor corrective action plan > Follow up inspection required. |
