POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: It was identified that not all staff were following policies and procedures for documentation, even though the tasks were confirmed completed.
Corrective Action(s): Ensure that all policies are implemented by employees.
Date to be Corrected: December 16, 2019
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: Review of one of five care plans for persons in care (PIC) determined that one PIC has had significant changes and the care plan is not updated to reflect these changes. Discussion was had with the Manager and the change in the care plan are in place and staff are aware of the changes but the care plan will still need to be revised to capture these short term changes.
Corrective Action(s): Ensure that each care plan is reviewed and modified if there is a substantial change in the circumstances of the person in care.
Date to be Corrected: December 16, 2019
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Review of the storage of incontinence products found that items were being opened and stored on open carts with multiple shelves. It could not be determined if staff were using products from the top or bottom of the shelves and it was confirmed that shelving did not have a regular cleaning schedule.
Corrective Action(s): Ensure that there is an established program for storage of hygiene products.
Date to be Corrected: December 16, 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 weights for all persons in care (PIC) determined that one month of weights within the last year was missed.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: December 16, 2019
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