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: During review of the medication administration, it was noted that one PIC's medication was removed from the medication package and was in a medication dispensary cup on the shelf, in the locked medication cabinet. The staff unlocked the cabinet and retrieved the medication to administer to the PIC after they were sitting at the table for breakfast. Review of the EMAR determined that the medication was signed for at 9:04 AM but was administered after that time.
Review of the MSAC policies and procedures for medication delivery, determined that staff "must deliver medications at the time, the dosage, and by the route prescribed by the physician. No medication are to be pre-poured".
Corrective Action(s): Ensure that all employee comply with the policies and procedures of the medication safety and advisory committee (MSAC).
Date to be Corrected: February 12, 2018
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Review of the facilities policies and procedures found that they were last reviewed May 2016.
Corrective Action(s): Ensure that all policies and procedures are reviewed and if necessary, revised at least once each year.
Date to be Corrected: March 1, 2018
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 2 of 5 PIC's care plans found the following:
-2 PIC's nutrition care plan documentation were last reviewed and dated January 20, 2017 and January 30, 2017.
-2 PIC's service and support plans were last reviewed and dated January 24, 2017 and January 30, 2017.
Corrective Action(s): Ensure that each care plan is reviewed and if necessary modified at least once each year to ensure that it continues to meet the need and preferences, and is compatible with the abilities, of the persons in care (PIC).
Date to be Corrected: March 1, 2018
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Review of the medication cabinet found a prescribed topical sunscreen that had expired in January 2018. It was noted that the Supervising Pharmacist had identified that 3 prescribed topical sunscreens had expired in the January 25, 2017 medication room inspection.
Corrective Action(s): Ensure that all PIC's medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Date to be Corrected: March 1, 2018
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