PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation (CORRECTED DURING INSPECTION): In 4 or more bathrooms/ shower rooms, the base of the transfer poles were rusted and the finish was completely removed, of concern is it is near the base of toilets and showers and is a potential injury risk due to damage and exposed rust, also making it difficult to clean/ disinfect.
Corrective Action(s): Ensure that all equipment for use by persons in care, are maintained in a safe and clean condition.
Date to be Corrected: corrected by day 2 of inspection
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: Of 5 staff files reviewed, 1 staff had an expired CRC
Corrective Action(s): Ensure all staff have obtained a CRC and it valid at all times during employment.
Date to be Corrected: Immediately
STAFFING: 32083 - RCR s.37(3)(c) - Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: One volunteer file reviewed did not contain evidence of screening or compliance with the Province's immunization and TB control program.
Corrective Action(s): Ensure all employees and staff have provided evidence of compliance with the Province's immunization and TB control program.
Date to be Corrected: May 3, 2024
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: for 3 of 5 PICs did not have written consent for the current restraint plan from the medical practitioner or family/guardian, as changes had been made on the restraint consent form.
Corrective Action(s): Ensure that consent for restraints is received in writing, from both the medical practitioner and family/ guardian before implementing the restraint, and anytime the plan is changed or modified. This is a repeat contravention from the 2022 routine inspection.
Date to be Corrected: May 3, 2024
CARE AND/OR SUPERVISION: 34080 - RCR s.49(3) - A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.
Observation: 5 of 5 PIC files reviewed did not have a completed elopement screening form, to identify whether a PIC is at risk of wandering.
Corrective Action(s): Ensure all PICs are assessed for elopement risk. This is a repeat contravention from the 2022 routine inspection.
Date to be Corrected: May 3, 2024
CARE AND/OR SUPERVISION: 34670 - RCR s.81(3)(e)(i) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (i) an assessment of the nature of the risk of falling presented by the person in care.
Observation: One person in care who was assessed as being a high falls risk, did not have a falls care plan in place.
Corrective Action(s): Ensure that for a person who is prone to falling, a falls care plan is in place.
Date to be Corrected: May 3, 2024
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: Four of five care plans reviewed had not been revised after significant changes in the PICs diet and fluid textures, oral health, mobility, and night time supervision.
Corrective Action(s): Ensure that PICs care plans are updated with any changes in the circumstance of the person in care. This is a repeat contravention from the 2022 routine inspection.
Date to be Corrected: May 3, 2024
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: One of five PIC files reviewed did not contain evidence that a PIC had been screened for TB risk.
Corrective Action(s): Ensure that all persons in care comply with the Province's immunization and TC control programs.
Date to be Corrected: May 3, 2024
|