PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: Inspection of the medication storage carts found that one medication cart was not being locked when staff walked away to administer medications (CORRECTED DURING INSPECTION).
Inspection of the tub/spa rooms found topical medications were left out and were not safely secured at all times.
Corrective Action(s): Ensure that medications are safely and securely stored at all times.
Date to be Corrected: December 16, 2019
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: Review of the staff performance evaluations determined that 25% of staff need to have their reviews completed. Discussion with the Management determined that this would be completed by the end of February 2020.
Corrective Action(s): Ensure that employee files are completed.
Date to be Corrected: February 25, 2020
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 the medications system found that staff were not following the medication safety and advisory committee (MSAC) policies and procedures for narcotic counts. It was also determined that staff were storing personal belongings in the medication rooms which does not comply with the facilities MSAC policies and procedures.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the MSAC.
Date to be Corrected: December 16, 2019
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Inspection of the tub/spa rooms determined that personal items were being left in the tub/spa rooms and were not labelled with individual person in care (PIC) names. Inspection of shared rooms determined that personal items were not labelled and were not being separated in the shared bathroom.
Corrective Action(s): Ensure that personal toiletries are labelled and separated with individual PIC's names.
Date to be Corrected: December 16, 2019
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Inspection of the small kitchens/servery found that baked goods were not labelled and dated. Discussion with staff determined that some servery staff will label the items after they are cold and others threw out the items at the end of day.
Review of the person in care fridges found that two fridges did not have temperature monitoring records.
Corrective Action(s): Ensure that all staff are consistent with their food service practice around baked goods.
Date to be Corrected: December 16, 2019
|