PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31590 - RCR s.30(b) - A licensee must ensure that all bathrooms have (b) slip resistant material on the bottom of each bathtub and shower.
Observation: Review of three occupied bedrooms and two unoccupied bedrooms, a slip- resistant surface in the bathtub was not provided to one person in care residing at the facility.
Corrective Action(s): Ensure that a slip-resistant material is provided on the bottom each bathtub and shower.
Date to be Corrected: June 29, 2018
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 five person in care’s medication records. For one person in care, although the medication was not received for the first two days of admission, the medication appeared to be documented as not received for the next two days after receiving the medications therefore creating a discrepancy in the medications records. In addition, there is no documentation of explanation aside for the numerical documentation on the MAR record.
One PRN medication was not updated on the MAR record to indicate the current medication administration schedule.
For one medication, administration times were not followed as indicated on the label.
Ensure medication policy and procedures are implemented by staff.
June 29, 2018
Corrective Action(s): Ensure medication policy and procedures are implemented by staff.
Date to be Corrected: June 29, 2018
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: In review of five persons in care records, consents for two persons in care were not completed on intake as required in the admission intake of persons in care.
Corrective Action(s): Ensure staff implement the policies and procedures of the facility.
Date to be Corrected: June 29, 2018
CARE AND/OR SUPERVISION: 34790 - RCR s.83(1)(a) - A licensee of a community care facility with 24 or fewer persons in care must (a) develop a nutrition plan for each person in care.
Observation: Please see code 39 320 RCR s.83(4)(a)
Corrective Action(s):
Date to be Corrected:
CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Observation: Please see code 39 320 RCR s.83(4)(a)
Corrective Action(s):
Date to be Corrected:
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: In review of five care records, two persons consented to be weighed monthly. Records indicate initial weights were documented and the persons in care were not weighed again after this initial weigh-in. There was no documentation on the reason for not being weighed for these persons in care. The persons in care were admitted in March and April of 2018. With one of these persons in care, the initial weight was indicated as above the indicated range for height and body mass index. There is no follow up documentation to indicate that a nutrition assessment is required at the time of dietary screening on intake. The manager stated that there is an appointment set with the dietician but was not initiated at time of intake. Of concern is the delay of follow up to this indicated concern.
Corrective Action(s): Ensure that each person is weighed at least once each month.
Date to be Corrected: June 29, 2018
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