LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: A review of the nutrition audits manual indicated the following, for example:
- One audit for dining environment is dated May 28. No year is noted.
- May 19, 2016 meal service audit not met in terms of percentage 100% and no action plan is noted take correction action.
- Dining environment audit dated June 24. No year noted.
- Nutrition Care Plan Audit Part A: Nutrition Care Plan 97% met and Part B: Weight Monitoring 98% met. Both categories "unmet" and no action plan(s) to take measures to address this. This audit was completed by the current Director of Care.
A review of 5 persons in care charts indicated that for the record of care sheets/documents, for example:
- One person in care who requires supervision with oral/dental care, nothing is charted/documented for April 12, 14, 15, and 16, 2017. For the month of April 2017, the table only lists dates from April 11 to 30, but no April 1 to 10. Therefore is it not clear from review of the documentation if oral care was provided April 1 to 10.
Corrective Action(s): Please ensure on-going self-monitoring of care and supervision systems is completed to ensure the intent of the Residential Care Regulation is being met.
Date to be Corrected: Please provide a comprehensive written response to these items by the timeline noted in this report.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31200 - RCR s.19(3) - If a licensee installs electronic devices for the purposes of transmitting or recording images of persons in care or members of the public, the licensee must display in a prominent place notice that electronic surveillance is being used.
Observation (CORRECTED DURING INSPECTION): There are video cameras for surveillance now at the facility (e.g., by the front door entrance on the 3rd floor by the nurses station).
Corrective Action(s): Please ensure video surveillance signage is posted so members of the public are aware.
Date to be Corrected: Please provide a written response to this item by the response timeline noted in this report. On July 20, 2017 when the writer delivered this report the video surveillance signage has been temporarily posted until signage is laminated.
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation (CORRECTED DURING INSPECTION): A random review of 4 staff files indicated that for 1 staff file the performance review was last done in 2015, even though the process is to have them done once a year. The Manager stated the notification for the electronic reviews did not trigger this for the year 2016. The Manager stated the review will be done for 2017.
Corrective Action(s): Please ensure all staff have regular performance reviews.
Date to be Corrected: Please provide a written response to this item by the response timeline noted in this report. On July 20, 2017 the General Manager stated the staff's appraisal has been completed dated July 18, 2017.
STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation (CORRECTED DURING INSPECTION): As per section 40(1)(a)(b) of the Residential Care Regulation.
Corrective Action(s): As above.
Date to be Corrected: As above.
STAFFING: 32260 - RCR s.44(1)(b) - A licensee must ensure that employees responsible for the preparation and delivery of food (b) receive ongoing education respecting the preparation and delivery of food, nutrition and, if required, assisted eating techniques.
Observation: For example the education done in January 2017 does not have a list of staff who attended noted.
For example the education done in March 2017 does not have a list of staff who attended noted.
For the year 2015, the only education documented is for July 8, 16, 23, and 28, 2015 and February 18, 2015.
For the year 2016 there is no education documentation noted at all.
The Manager stated the attendance by staff sheets are going to be centralized.
Corrective Action(s): Please ensure as per the Residential Care Regulation section referenced that on-going education is completed.
Date to be Corrected: Please provide a written response to this item by the response timeline noted in this report.
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: The Manager indicated that the last medication safety and advisory committee meeting minutes are from 2015. The writer was provided a copy of the March 24, 2017 medication systems inspection. The Manager stated they have contacted the Pharmacist to address this issue.
Corrective Action(s): Please ensure the Medication Safety and Advisory Committee meets on a regular basis as per the Residential Care Regulation and that current / up to date minutes are kept.
Date to be Corrected: Please provide a written response to this item by the response timeline noted in this report.
POLICIES AND PROCEDURES: 33150 - RCR s.68(3(b)(ii) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (ii) the immediate response to and reporting of medication errors and adverse reactions to medications.
Observation: As per Section 68 (3)(b)(i) of the Residential Care Regulation.
Corrective Action(s): As above.
Date to be Corrected: As above.
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: A random review of 5 care plans indicated that several areas such as oral/dental care did not have current dates. One oral/dental care plan is dated from the year 2014. Some care plans appear not to have been reviewed and are over 1 year old.
Corrective Action(s): Please ensure that all care plans are reviewed on a regular basis and revised as required.
Date to be Corrected: Please provide a written response to this item by the response timeline noted in this report.
RECORDS AND REPORTING: 39330 - RCR s.83(4)(c) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (c) record the weight in the nutrition plan of the person in care.
Observation: In discussion with the Dietitian they indicated that weights need to be completed by the 10th day of each month and for example for 1 care floor/unit, 8 weights have not yet been recorded.
Corrective Action(s): Please ensure monthly weights are documented as required. Please let the writer know what measures will be taken to address this.
Date to be Corrected: Please provide a written response to this item by the response timeline noted in this report.
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