LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: A random review of the persons in care documentation indicated that for one particular document it was last reviewed in 2017 (Specifics provided during the inspection).
A random review of the persons in care documentation indicated that there appeared to be significant change in weight as discussed at the time of the inspection. It was explained that the person in care has not lost any significant weight and will reinforce with all the care staff around ensuring documentation is thoroughly and accurately noted. Please note: A weight is noted that appears to be a significant change, however there is no indication why the weight is significantly lower. Please ensure if there is a significant change in weight that the appropriate intervention and follow-up take place with the relevant health care professionals.
Corrective Action(s): Please ensure the care and services provided by the home are regularly monitored to ensure that the requirements of the Community Care & Assisted Living Act and Residential Care Regulation are being met.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A random review of the physical plant for example indicated right outside the dining room/kitchen there appears to be wood rotting on the top of the fence. The Manager stated they have contacted BC Housing around this.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (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: A random review of persons in care records indicated restraints did not have the Doctor sign off/date the documents except for one which is not current in terms of the date (Specifics provided during the inspection).
Corrective Action(s): Please ensure that the use of a restraint is given in - writing by the medical or nurse practitioner as per section 74 (1)(b)(ii) of the Residential Care Regulation.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: Fire drills are to be completed on a monthly basis. The fire drill for October 2018 is not noted. The Manager stated that they would follow-up on this.
Corrective Action(s): Please ensure fire drills are completed as per protocol/policy.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39330 - RCR s.83(4)(c) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (c) record the weight in the nutrition plan of the person in care.
Observation: A random review of persons in care documentation indicated a weight was not documented (Specifics provided during the inspection).
Corrective Action(s): Please ensure monthly weights are consistently documented for all persons in care.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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