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: Random hot water temperatures that were taken indicated for 1 ensuite washroom sink the temperature was noted to be 54.6 degrees Celsius.
Corrective Action(s): Please ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: During the June 27, 2023 inspection, the Facility Management Operations (FMO) was made aware to address this.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: For example in two ensuite washroom when entering the washroom on the bottom left lower area near the flooring, the wall had paint come off and drywall starting to show.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: August 31, 2023.
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: A review of the hospice documentation titled "non opiod medication administration" for medications administered as "prn" (as needed) it was noted for example 3 entires with no result/effectiveness documented.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: July 5, 2023.
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: There is no agreement to the use of a restraint given in writing as required by Section 74 (1)(b)(i) of the Residential Care Regulation for a person in care.
Corrective Action(s): Please ensure the requirements of Section 74 (1)(b)(i) of the Residential Care Regulation are met where required.
Date to be Corrected: July 17, 2023.
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: There is no agreement to the use of a restraint given in writing as required by Section 74 (1)(b)(ii) of the Residential Care Regulation for a person in care.
Corrective Action(s): Please ensure the requirements of Section 74 (1)(b)(ii) of the Residential Care Regulation are met as required.
Date to be Corrected: July 17, 2023.
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: Post Fall Management documentation not completed in full. For example for two falls for a person in care the section for family notification not initialed by the staff when it should have been. Specifics provided during the inspection.
Corrective Action(s): Please ensure that policies are implemented by employees.
Date to be Corrected: July 5, 2023.
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: In review of the medication system, there were medications not labelled by the Pharmacist (specifics reviewed during the inspection).
Corrective Action(s): Please ensure the Pharmacist packages all medications.
Date to be Corrected: July 17, 2023.
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection 77(3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: It was noted that one incident that occurred in May 2023 was not reported to Community Care Facilities Licensing.
Corrective Action(s): Please report all reportable incident reports in the time frame they are to be submitted.
Date to be Corrected: June 30, 2023.
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