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 40(2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: A review of 2/8 staffing files found no current performance evaluation on file as per the facilities employee performance evaluation policy.
Corrective Action(s): Ensure regular performance evaluations are completed as per facility policy.
Date to be Corrected: April 8, 2022
STAFFING: 32250 - RCR s.44(1)(a) - A licensee must ensure that employees responsible for the preparation and delivery of food (a) have the experience, competence and training necessary to ensure that food is safely prepared and handled and meets the nutrition needs of the persons in care.
Observation (CORRECTED DURING INSPECTION): A review of 1/8 staffing files found that an employee did not have a current food safe certification on file.
Corrective Action(s): Ensure that employees responsible for food preparation and service have the necessary training.
Date to be Corrected: April 8, 2022
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 review of 4 PIC's narcotic drug count sheet had inconsistencies on several occasions whereby the second nurse signature/initial was not documented. A review of their narcotic drug count policy confirmed that two signatures/initials are required during the narcotic drug count.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: April 8, 2022
CARE AND/OR SUPERVISION: 34370 - RCR s.63(3)(c)(iv) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iv) reassessed by the person in care's medical practitioner, nurse practitioner or dietitian at least once every 30 days.
Observation: A review of 2/10 PIC's care plan indicated they are receiving ongoing tray service however, the reassessment did not occur within the last 30 days.
Corrective Action(s): Ensure that ongoing tray service is reassessed by the PIC's medical practitioner or dietician at least once every 30 days.
Date to be Corrected: April 8, 2022
CARE AND/OR SUPERVISION: 34570 - RCR s.75(3)(b) - If a restraint is used under section 74(1)(b) and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must (b) as part of the reassessment, consult, to the extent reasonably practical, with the persons who agreed to the use of the restraint.
Observation (CORRECTED DURING INSPECTION): A review of 1/10 PIC's care plan indicated use of a restraint however, the restraint agreement form found in the care plan was not reassessed since November 30, 2018.
Corrective Action(s): A licensee must ensure reassessment includes consultation with the persons who agreed to use the restraint.
Date to be Corrected: April 8, 2022
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: A review of 1/10 PIC's care plan found a negotiated risk agreement which was not reassessed quarterly as indicated on the form.
Corrective Action(s): Ensure that each care plan is monitored on a regular basis to ensure proper implementation.
Date to be Corrected: April 8, 2022
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 2/10 person in cares care plan found the following:
- A PIC indicated use of a restraint. Further discussion with the leadership advised the restraint is no longer in use however, this change was not captured in the care plan.
- An ADL indicated the PIC required use of a restraint but was not captured in the PIC's care plan.
Corrective Action(s): Ensure that each care plan is reviewed and if necessary, modified if there is a substantial change in circumstances of the person in care.
Date to be Corrected: April 8, 2022
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Inspection of the medication cart found one medication had expired February 2, 2022.
Corrective Action(s): Ensure that person in care's medication is returned to the pharmacy if the expiry date on the medication has passed.
Date to be Corrected: April 8, 2022
RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation (CORRECTED DURING INSPECTION): A review of 2/10 PIC's care plan found the following:
- 1 PIC without evidence of TB status.
- 2 PIC without evidence of immunization status.
Corrective Action(s): Ensure that for all PIC's a record is kept of TB and immunization status.
Date to be Corrected: April 8, 2022
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(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 2/10 person in care's care plan found the following:
- 1 PIC's weights were not obtained in November/December 2021 and no reason was documented as to why the weight was not taken.
- A PIC's weight was not obtained during admission and no reason was documented as to why the weight was missing.
Corrective Action(s): Ensure weights are obtained for person's in care or provide a reason as to why the weight could not be obtained.
Date to be Corrected: April 8, 2022
|