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: Observed in the lobby area was a portable air conditioning unit that appeared to have mold/or mildew on the vents. Of concern are the health implications this may present to those in the vicinity.
Corrective Action(s): Ensure equipment is maintained in a safe and clean condition to prevent any risk to the health and safety of persons in care.
Date to be Corrected: 12 Oct 2018
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: It was observed in one PIC’s room that the Activities of Daily Living (ADL) sheet had not been updated to reflect a purple dot status, indicating a known risk for aggressive behaviour.
Corrective Action(s): Ensure the ADL is updated as part of the care plan used to guide staff in providing care.
Date to be Corrected: 12 Oct 2018
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: It was observed that the last completed nutrition audit was in 2016. Discussion with the Dietician indicated that he has just started his position at Bevan Village in mid-August and has been working to implement a system of self-monitoring that would include meal audits occurring quarterly. He recognized that there had been a one month gap when the facility was without a dietician on staff. He also indicated he is currently re-assessing all residents in care using the new standardized nutrition assessments now being used at Bevan Village.
Corrective Action(s): Ensure all nutrition audits and assessments are completed as per the schedule in place and that records of these audits are maintained.
Date to be Corrected: 26 Oct 2018
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