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: Upon inspection of the facility narcotic count book, it was observed that the dosage count and the wasted narcotic was not signed off on.
Corrective Action(s): Ensure that employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: December 31, 2021
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: Upon review of facility post falls assessment, it was determined that one was in complete. The neuro-vital assessments were not conducted at the required intervals for the required duration of time.
Corrective Action(s): Please ensure that post falls assessments are conducted as per the policy in place.
Date to be Corrected: December 31, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Upon inspection of the facility spa room, there were observed a hairbrush and hair tie that had been used, as evidenced by the presence of hair. Of concern is the implements were not labelled specifically for use with one person in care (PIC). These items are not for shared use.
Corrective Action(s): Assist PIC's with maintaining health and hygiene
Date to be Corrected: December 31, 2021
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