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: The following were observed:
1). 1/5 PIC's bedroom wall at the entry has paint chipped off exposing drywalls, has a 3x3cm hole and there is evidence of wheelchair scruff marking on the walls around the entry door.
2). 1/5 PIC's bathroom has a piece of tile flooring come off lose with evident softness noted on the underlayer due to water seepage. Of concern is maintaining adequate cleanliness and hygiene.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: August 16, 2022
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: 2/5 PRN medications administered in June & July did not have the effectiveness of the PRN documented on the PRN Effect Documentation Monthly record and staff also did not initial the document as per policy for 3/5 PICs several times in the same months. This was brought to the attention of the staff person assisting with the inspection.
Corrective Action(s): Please ensure that all staff comply with the policies and procedures of MSAC.
Date to be Corrected: August 16, 2022
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: 1/3 PICs with restraint monitoring plan every 2-3 hours was found to be completed once per shift. There was no documentation to indicate that restraint monitoring was completed as per care plan.
Corrective Action(s): Please ensure that the care and supervision of a PIC is consistent with the terms and conditions of the PIC's care plan
Date to be Corrected: August 16, 2022
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