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: It was observed in three persons in care rooms that the Activities of Daily Living (ADL) sheet was dated 2017 and did not indicate that it had been reviewed or modified on a monthly basis as per protocol of this facility.
Corrective Action(s): Ensure the ADL sheet is reviewed and modified as necessary as part of the care plan. Ensure this review is documented
Date to be Corrected: 14 Nov 2018
RECORDS AND REPORTING: 39370 - RCR s.84(d) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (d) the duration of the restraint and the monitoring of the person in care during the restraint.
Observation: The care plan did not have a record of monitoring of a restraint for a person in care. The restraint was required to be monitored on an hourly basis and had been completed until 26 Oct 2018. Upon inspection of the electronic care plan, it was discovered that the prompt for monitoring had been cancelled. The person in care still requires the restraint and as such requires the monitoring.
Corrective Action(s): Ensure the monitoring of the restraint is recorded hourly.
Date to be Corrected: 07 Nov 2018.
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