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: - Review of 4 persons in care (PIC) records, a 17 page document called the health care plan in both the person's individual care binder and Medication Administration Record (MAR) binder dated 2015, which were observed to not have the most current information about the PICs. The individual binders also contained quarterly updated health care records with the most current information regarding the PIC. The MAR binder is also the "grab and go" binder in an emergency, but would potentially not have the most updated information regarding the PIC. Also of concern, is the access of staff to inconsistent information regarding the PIC.
- Review of 2 of 4 PIC records, the last date on the restraints approval form was 2015. The form states an annual review is required.
Corrective Action(s): Ensure care records are updated in all areas to ensure consistent information is provided to guide staff to meet the current needs and preferences of the PICs.
Date to be Corrected: August 4, 2017
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