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: Review of 6 Persons in Care(PICs) Medication Administration Records (MAR) found more than 25 instances where the effects of PRN medications were not documented. This is required per the policy of the Medication Safety & Advisory Committee.
Corrective Action(s): Please ensure that policies are implemented by employees.
Date to be Corrected: September 1, 2023
NUTRITION AND FOOD SERVICES: 37105 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation: Inspection of each of the dining areas determined no evidence of the weekly menus posted; discussion with dietary staff confirmed that weekly menus have not been posted since before the COVID-19 pandemic.
Corrective Action(s): Please ensure that the weekly menus are displayed in a prominent place in each dining area.
Date to be Corrected: September 1, 2023.
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 6 PIC charts determined that 2 of 6 did not have evidence of 2 or more monthly weights; 1 PIC was missing 2 weights in the last 12 months and the second PIC was missing 3 weights in the last 12 months.
Corrective Action(s): Please ensure that each PIC is weighed at least once each month.
Date to be Corrected: September 1, 2023.
|