PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: A random review of the physical plant indicated in one bedroom upon entering it, the carpet is showing wear and tear. The Manager stated they will follow-up on this.
Corrective Action(s): Please ensure on-going self monitoring is taking place as per section 61 of the Residential Care Regulation and that on-going routine maintenance is being addressed as required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A random review of the medication administration system including the medication administration records, medication cupboard, etc. indicated that for one person in care they were given a PRN (as needed) medication with no result noted. The Manager stated they will follow-up on this as the back of the medication administration record sheets don't have an area for staff to document (Manager will follow-up on this with the Pharmacist as well).
For one person in care their medications are dropped off by the Pharmacist in the evening and documented as being taken by the person in care. The Pharmacist also leaves medications for the next morning, however there is no documentation for example on the medication administration records that staff administered the medications (no staff initials). The Manager stated they will follow-up on this.
Corrective Action(s): Please ensure staff are charting for PRNs including the result/outcome. Please also ensure that all medications being administered to persons in care are being charted/initialed as well.
Date to be Corrected: Please provide a written response to this item by the 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: A random review of three persons in care monthly weights indicated for one person in care their weight for September 2017 is not documented. The Manager stated they will follow-up on this. For another person in care, the Manager indicated that their weights are not documented and are completed at the Doctor's office. The Manager stated they will touch base with the Doctor's office to get this information as it needs to be documented at Aster House.
Corrective Action(s): Please ensure all persons in care have their monthly weights documented and if there is any reason(s) why the weight is not documented then that should be documented accordingly (e.g., weight scale is not functioning, person in care is refusing to be weighed, etc).
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: A review of the nutrition audits indicated a menu checklist is completed, however the audit of the menu(s) is not in-place. The Manager stated they will follow-up on this.
Corrective Action(s): Please ensure nutrition audits are occuring on a regular basis.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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