STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: Records of 5 employees were reviewed and the criminal record check for 1 employee had expired and was no longer valid.
Corrective Action(s): Please ensure a person is not employed if a criminal record check as not been obtained.
Date to be Corrected: Immediately.
CARE AND/OR SUPERVISION: 34370 - RCR s.63(3)(c)(iv) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iv) reassessed by the person in care's medical practitioner, nurse practitioner or dietitian at least once every 30 days.
Observation: One person in care (PIC) who is provided with ongoing room tray service, has not had a reassessment completed since first being ordered in November 2022.
Corrective Action(s): Please ensure ongoing room tray service is reassessed as required, every 30 days.
Date to be Corrected: February 15, 2023
CARE AND/OR SUPERVISION: 34640 - RCR s.81(3)(c)(i) - A care plan must include all of the following: (c) a nutrition plan that (i) assesses a person in care's nutrition status.
Observation: The care plans for five persons in care (PIC) were reviewed and two did not include a nutrition plan.
Corrective Action(s): Please ensure all PICs have a nutrition plan included in their care plan.
Date to be Corrected: February 15, 2023
CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: The care plans for five persons in care (PIC) were reviewed and three had no recreation and/or leisure plan included.
Corrective Action(s): Please ensure every PIC has a recreation and/or leisure plan included in their care plan.
Date to be Corrected: February 15, 2023
CARE AND/OR SUPERVISION: 34690 - RCR s.81(3)(e)(iii) - 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 (iii) a plan for following up on any falls suffered by a person in care.
Observation: The care plans of five persons in care (PIC) were reviewed and two PICs did not have a plan for following up on a fall, included in their fall prevention plan.
Corrective Action(s): Please ensure that the fall prevention plan for all PICs includes a plan for following up on a fall.
Date to be Corrected: February 15, 2023
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: A review of the care plans of five persons in care (PIC) were reviewed, and the following was determined:
- The recreation and leisure plan for one PIC included goals no longer required as the status of the PIC had changed.
- The care plan for one PIC included information that was inconsistent regarding the number of staff required to provide care. Due to changes in the care required, two staff were to be present at all times, however the care plan directed only one staff be present in some instances, which was no longer sufficient.
-The care plan for one PIC included inconsistent information related to the PIC requiring the use of hip protectors to minimize injury from falls.
- The care plan for one PIC included inconsistent information related to the diabetic diet they required.
- The care plan for one PIC included inconsistent information related to a restraint while in their wheelchair.
- The care plan for one PIC included a plan in response to a wound, however was not updated when a second wound in a different location developed.
Corrective Action(s): Please ensure the care plan of a PIC is reviewed and revised as their care needs change.
Date to be Corrected: February 15, 2023
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: The records of five persons in care (PIC) were reviewed and one contained no evidence the PIC was in compliance with the Province's immunization and tuberculosis control programs. A second PIC had a TB screening form that had not been completed in full.
Corrective Action(s): Please ensure all PICs are in compliance with the Province's immunization and TB control programs.
Date to be Corrected: February 15, 2023
RECORDS AND REPORTING: 39160 - RCR s.78(1)(d) - A licensee must keep, for each person in care, a record showing the following information: (d) information by which the person in care may be described or identified in an emergency, including a photograph.
Observation: The records of 5 persons in care (PIC) were reviewed and 4 included a form to be completed by staff to ensure identifying and descriptive information of the PIC was documented. The form was not completed in full for 4 of the PICs, missing some or all information. 1 PIC did not have the form or any other document containing the required documentation in their record for review.
Corrective Action(s): Please ensure all PICs have a record with information by which they could be described or identified in an emergency.
Date to be Corrected: February 15, 2023
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