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: 4 of the 6 person in care (PIC) records reviewed contained Admission checklist and documentation that was incomplete. The facility policy requires that the checklists are to be completed.
This was corrected by day 2 of the inspection.
Corrective Action(s): Please ensure that the policies and procedures are implemented by staff.
Date to be Corrected:
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: A review of records for six persons in care (PIC) determined the following:
-One PIC care plan and other records when compared contained discrepancies between if the person required a walker or a wheelchair for locomotion, if they required the use of compression stockings, the level of supervision required during care and the use of a mechanical lift. The person in care required to be check every 1 hours due to elopement risk, however this was not on the care plan.
-A second PIC care plan and other records when compared contained discrepancies between the required diet, one record instructed staff to provide thin fluids, and a second record required staff to provide thickened fluids. A completed assessment stated that the PIC needed a mechanical lift for transfer , however this was not in the care plan. The care plan contained instruction to the staff to provide wound care, however the PIC no longer required this action.
- A third PIC care plan and other records when compared contained discrepancies. Information in the bedroom instructed staff that due to a wound, the PIC required specific care, however this was not included in the care plan and staff reported that the PIC no longer required this action. One record informed staff that the PIC had a specific diagnosed that was not included in the rest of the PIC record. One record instructed staff to provide a minced diet and a second instructed staff to provide a cut up diet. Care plan does not provide information to staff to provide a nutritional supplement as required or use a bed alarm as indicated in other records.
-A fourth PIC record indicates staff are to monitor for behaviors, however this is not in the care plan. The care plan also indicates that 1 bed-rail is to be used and a second record instructs 2 to be used.
-A fifth PIC care plan does not provide information that the PIC requires the use of specialty equipment in bed as well as a nutritional supplement. No care plan instruction to staff on how to transfer the PIC from bed to their wheelchair, however an assessment completed on admission indicated that the PIC would need a mechanical lift.
These items were correct by day two of the inspection.
Corrective Action(s): Please ensure that care plans are reviewed and updated as required if there is a change in the care needs of the PIC(s).
Date to be Corrected:
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: 5 of the 6 records reviewed contained immunization and tuberculosis screening forms that were incomplete.
Corrective Action(s): Please ensure that all persons in care comply with the Province's immunization and tuberculosis control programs.
This was correct by day 2 of the inspection.
Date to be Corrected:
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: In a review of records an allegation of neglect of a person in care in September 2020 was documented to have occurred, however this was not submitted to the medical health officer as a reportable incident as required.
Corrective Action(s): Please ensure that if a person in care is involved in a reportable incident, that the licensee immediately notifies a medical health officer in the form and in the manner required.
Date to be Corrected:
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