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: Upon observation of 5 charts, it was determined that there is not a system in place to ensure staff are implementing process when the resident charts and documentation was reviewed. It was determined that there was inconsistent completion of the following:
- post fall management management checklists
- short term care plans, including focus of care sections
- 7 day observation forms
- move- in day interviews
- fall risk assessments
Corrective Action(s): Ensure there is a system in place to monitor all aspects to ensure that the requirements of the regulations are being met.
Date to be Corrected: March 26, 2021
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: It was observed that witness signatures were not completed for 2 narcotics count upon review of January and February 2021.
Corrective Action(s): Ensure all staff follow the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: March 26, 2021
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: It was observed that one person in care's Aggressive Risk Behaviour was not updated since Jan 31, 2020.
Corrective Action(s): Ensure care plans are reviewed at least once each year, unless there is a significant change.
Date to be Corrected: March 26, 2021
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