PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Water temperature in two persons in care's rooms exceeded 49 degrees Celsius.
Corrective Action(s): Ensure water, accessible to persons in care, is not heated to more than 49 degrees Celsius.
Date to be Corrected: 26 Oct 2018
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 (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: An audit of five staff files was completed and all five did not have evidence of performance reviews being completed.
Corrective Action(s): Ensure the performance of each employee is reviewed regularly. Submit a compliance plan with timeline as to when performance reviews will be completed.
Date to be Corrected: 26 Oct 2018
CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (ii) a plan for preventing the person in care from falling.
Observation: A review of persons in care's records found that two of five records reviewed did not have fall prevention plans in place.
Corrective Action(s): Ensure that fall prevention plans are in place for persons in care.
Date to be Corrected: 26 Oct 2018
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: A review of five persons in care's records found that careplans had not been reviewed in the last year. Discussions with the Assistant General Manager indicates that Care Conferences have not been completed as there has not been a Medical Director in place. The facility now has most of its residents using cluster care physicians. Currently a schedule of Care Conferences for all persons in care is being created and planned to be completed prior to the end of the year.
Corrective Action(s): Ensure each care plan is reviewed, and if necessary modified, at least once each year. Provide a written response to Licensing to include a schedule of all upcoming Care Conferences.
Date to be Corrected: 26 Oct 2018.
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: A review of five persons in care records was completed and found that three records did not include completed immunization/tuberculosis screening forms.
Corrective Action(s): Ensure all persons in care comply with the Province's immunization and tuberculosis control program.
Date to be Corrected: 19 Nov 2018
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