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: Review of the Medication Administration Records (MAR) for 3 of 4 persons in care (PIC); determined that the PRN's records were not complete and the back of the MAR sheet did not provide for an area to record the following: PRN date administered; PRN reason; PRN results; etc. The facility MSAC policy requires this information to be recorded and it was not captured.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: March 5, 2019
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Review of the menu documentation found a menu substitution list form but no completed menu substitution list. It was determined by the menu that meatballs were on the dinner menu but staff confirmed that the pork chops defrosting in the fridge were for dinner. Staff confirmed that they do not complete the menu substitution list.
Corrective Action(s): Ensure that each menu provides for substitutions to be made that are from the same food group and have a similar nutritional value.
Date to be Corrected: March 5, 2019
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of the weights for 1 person in care determined that no weight was recorded for December 2018 and no reason was given for the weight not being obtained.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: March 5, 2019
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