LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: Examples:
* The staff signing sheet in the medication administration record was noted with a few staff that did not complete this signing sheet. Specifics given during the inspection. The Manager will follow-up with the staff.
* For a person in care the Food and Nutrition Document was last reviewed on January 5, 2019 and on the computerized system it states the next review should have been on January 5, 2019. The Manager will follow-up on this item.
* For a person in care the Nutrition Satisfaction Survey was last completed on January 5, 2018 and a survey has not been completed in 2019. The Manager will follow-up on this item.
Corrective Action(s): Please ensure the care and services provided by the home are monitored regularly to ensure that the requirements of the Act and Residential Care Regulation are being met.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: In the front living area by the computer is a small refrigerator that only has a latch on the top left corner. There is one cream/gel in the refrigerator for a person in care. In discussion with the staff that the writer spoke to previously other medications were also stored in the refrigerator. The writer advised the staff and the Manager/Program Coordinator that all medications must be safely and securely stored at all times.
Corrective Action(s): Please ensure all medications are safely and securely stored at all times.
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 records indicated for example:
* A PRN (As needed) medication was charted/initialed eight times on the front of the medication administration records, however a May 26, 2019 entry was was not initialed for on the front of the medication administration record, but was charted with the effect on the back of the medication administration record.
* Two medications were charted/initialed for May 28, 2019 on the front of the medication administration records, eventhough it is only May 27, 2019.
Corrective Action(s): Please ensure all staff comply with the policies and procedures of the Medication Safety & Advisory Committee.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: Fire drills are to be completed once a month. There is no fire drill for October 2018.
Corrective Action(s): Please ensure all staff implement the policies and procedures.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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