All items from the routine inspection report appear to have been addressed.
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A discussion took place with the Dietitian who will follow-up on the October 11, 2018 meal service audit which needs to be scored and a action plan put together. The one item from this audit that was not met was noted by the Dietitian and a follow-up / action plan will be put together. Overall all the nutrition audits appear to be thorough and a schedule of when the audits are to be done is in-place.
A discussion took place with the Director of Care regarding the revised record of care documents which documents for example oral care, etc. Overall a random review of this document for several persons in care appeared to be thoroughly documented. There was one day not noted for a person in care and the Director of Care will follow-up. The writer was shown in-service documentation with participation records of staff who attended regarding this document. As overall the documentation was very thorough, this item was not coded as a contravention.
A discussion took place with the Director of Care around PRN (as needed) medications and effectiveness / results to be noted. Overall the medication administration record book randomly reviewed appeared to have the PRN results/effectiveness thoroughly documented. There was one discrepancy discussed with the Director of Care (specific details provided) and the Director of Care will follow-up. The writer was shown in-service documentation with participation records of staff who attended regarding PRN charting. As overall documentation was very thorough, this item was not coded as a contravention.
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In discussion with the General Manager:
* Confidentiality of persons in care charts options are being looked at and this has been put forward into the capital improvement plan for 2019. In the interim, if issues arise with the current set-up of persons in care charts, please ensure measures are taken to ensure the confidentiality of the charts and related documentation for all persons in care.
* The courtyard whereby a concrete pathway will be put in leading to an outside exit, quotes have been received and the tree that is in the way would need to be cut. The General Manager stated there is another emergency exit nearby that can be used. The timer on the door leading out to the courtyard has been adjusted by a company. This has been added to the capital improvement plan for 2019.
Overall it appears documentation/charting has greatly improved. Thank you for all the work that has been completed to address the items from the routine inspection report.
Thank you for your time to complete this inspection and if there are any questions, please contact your Licensing Officer. |