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: Of all rooms reviewed there was only one room that was observed to contain a variety of OTC medications contained in the multiple containers in the bathroom. The resident reported she was newly admitted.
Corrective Action(s): Please provide a plan that will ensure that all residents are aware that regulations require secure storage of all medications.
Date to be Corrected: Feb. 22, 2018
STAFFING: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: Of 4 Recreation file records reviewed references and work history were not observed in the records.
Corrective Action(s): Please provide a plan that will ensure that references and work histories are obtained for all employees.
Date to be Corrected: March 1, 2018
STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Of 9 staff records reviewed 2 were missing evidence of compliance with TB status
Corrective Action(s): Please ensure that the status of compliance with the BC Immunization and TB program is available for inspection.
Date to be Corrected: March 1, 2018
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 (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Of 9 staff files reviewed, a current performance review was not observed for 3 staff.
Corrective Action(s): Please ensure that performance reviews for all staff, occur at intervals identified by the facility policy.
Date to be Corrected: March 1, 2018
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: Of 9 staff, valid First Aid and CPR was not observed for 2 staff, one being a recreation staff who may be alone with residents on outings.
Corrective Action(s): Please provide a plan that will ensure that as per the regulation above, all residents at all times have access to staff with valid First Aid and CPR
Date to be Corrected: March 1, 2018
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: The policy regarding qualification for recreation staff requires food safe. The medication policy requires PRN medications be documented on the reverse of the MAR identifying "results" of the drug administration.
Corrective Action(s): On the employee qualification records provided by human resources, food safe qualification was not observed for 2 employees. Recreation staff conduct cooking and baking sessions with residents and the products are made available for consumption to the staff and residents. One resident file recorded 5 times a PRN was administered, only 3 were recorded on the reverse of the MAR and the "results" were not always recorded.
Date to be Corrected: March 1, 2018
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: In discussion with 2 staffs, it was determined that there is a lack of supervision for food service. For example, it has been found that residents do not receive prune juice, as directed in their care plan, during food service. When questioned by dietary and nursing staff, the serving staff state that the resident had refused the juice. The juice is considered important for gastrointestinal health. The resident's refusal may or may not be reported to the nurse in order to be recorded. There are resident meal plans kept in the "Suzy Q" food service cart drawer, but the staff were reported not to use it consistently and errors in service occur.
Corrective Action(s): Please provide a plan that will ensure that all residents receive their nutrition according to their care plan, and that when refusal occurs it is appropriately recorded. Also indicate how the service outcomes will be monitored.
Date to be Corrected: March 1, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: The facility description for food service employees requires Food Safe training, recreational staff bake cookies with residents. There was no Food Safe Certificates noted for one Food Service staff on the qualification documents provided, and none of the recreation staff.
Corrective Action(s): Please provide a plan that ensures that all food is managed safely, food safe is up to date for all staff and documented appropriately for inspection.
Date to be Corrected: March 1, 2018
MEDICATION: 36100 - RCR s.70(1) - A licensee must ensure that only medications that have been prescribed or ordered by a medical practitioner or nurse practitioner are administered to a person in care.
Observation: Medications were observed in a resident room that had not been labelled as being ordered by a medical/ nurse practitioner
Corrective Action(s): Please provide a plan that will ensure that medications not ordered by a practitioner are not available to residents to use.
Date to be Corrected: March 1, 2018
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: The substitution list was reviewed in the kitchen. Many of the substitutions were not in the same food group or the same nutritional value.
Corrective Action(s): Please provide a plan that will ensure that the substitution list and the substitutions are from the same food group and similar nutritional value.
Date to be Corrected: March 1, 2018
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: Weights are to be measured at the time of the daily bath in the first week of the month. There were some weights missing, no reason was recorded.
Corrective Action(s): Please provide a plan that will ensure that if a weight is not recorded that the reason is documented.
Date to be Corrected: March 1, 2018
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