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: Inspection of the two medication storage rooms found that the doors were open and 3 of the 4 medication carts were not locked.
Corrective Action(s): Ensure that all medications in the community care facility are safely and securely stored.
Date to be Corrected: January 20, 2020
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: Review of the medication storage room found the following:
- one medication that required refrigeration was stored in the medication cart
- all computers were signed on and open to the medication administration when staff were not utilizing the system
- personal items were being stored in the medication rooms
- staff food was being stored in the medication fridges
- a lab sample that required refrigeration was stored on the cart
- pudding used to administer medications was left in an open container
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: January 20, 2020
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: Review of the medication returns determined that there has been a change in how medications are returned but there was no policy to ensure compliance with the Pharmacy Operations and Drug Scheduling Act.
Corrective Action(s): Ensure that policies and procedures are established and current.
Date to be Corrected: January 20, 2020
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 the care plans found that staff were not completing care plan documentation for short term care plans.
Corrective Action(s): Ensure that employees follow facilities policies and procedures for documentation.
Date to be Corrected: January 20, 2020
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Inspection of spa room found items that were not labelled and it could not be confirmed if they were for universal use or individual use. Inspection of the clean storage and carts found incontinence pads out of their packages and stored directly on shelving. Discussion with staff could not confirm a regular cleaning schedule for universal spa items, storage shelves, and carts.
Corrective Action(s): Ensure that there is a program to assist persons in care in maintaining health and hygiene..
Date to be Corrected: January 20, 2020
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Inspection of the two food serveries found that food had been left uncovered, was not labelled or dated, and items that should be refrigerated were left out. There was no thermometer found in the fridges and the recorded fridge temperatures were not within the safe storage range.
Corrective Action(s): Ensure that all food is safely stored, served, and handled.
Date to be Corrected: January 20, 2020
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: Review of one medication room found an over the counter (OTC) medication that did not have a pharmacy label.
Corrective Action(s): Ensure that all medications are packaged by the pharmacist.
Date to be Corrected: January 20, 2020
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: Review of 3 of 6 care plans found that weights monthly weights were missing.
Corrective Action(s): Ensure that each person in care is weighed at least once each month or a reason is provided as to why the weight could not be obtained.
Date to be Corrected: January 20, 2020
RECORDS AND REPORTING: 39670 - RCR s.93 - A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of persons in care, keep the records and personal information of persons in care confidential.
Observation: Inspection of the facility found that for information related to certain persons in care is openly visible.
Corrective Action(s): Ensure that personal information of persons in care is kept confidential.
Date to be Corrected: January 20, 2020
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