PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Review of one of the main washrooms found the water temperature to be 50.5 degrees Celsius and climbing.
This is a repeat contraventions from last years routine inspection (inspection report #KDHL-AFS2QN).
Corrective Action(s): Please ensure that the water temperature does not exceed 49 degrees Celsius in areas that are accessed by persons in care.
Date to be Corrected: December 1, 2017
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: 2 out of 11 employee files reviewed found that 2 employees have not had performance appraisals since 2015. Discussion with a staff member determined that the appraisals are supposed to be conducted every year.
Corrective Action(s): Please ensure that employees receive regular performance appraisals to ensure that the employee demonstrates the competence required to perform their duties.
Date to be Corrected: December 12, 2017
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: The policies and procedures for medication administration state that employees are to initial for having given medications and to record all results for administered PRNs on the back of the PICs MAR.
4 out of 5 PICs MARs had at least 4 medications not signed for even though they were administered and 1 out of 5 MARs did not have the results recorded on the back of the MAR for the PRNs that were administered.
Corrective Action(s): Please ensure that all employees comply with all of the medication safety and advisory committees policies and procedures.
Date to be Corrected: November 28, 2017
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Review of the kitchen's fridge found that there were at least 5 items that were not labelled that had been removed from their original packaging. Discussion with the manager determined that some of the items would be used today, but some would be put back into the fridge for continued use another day.
Corrective Action(s): Please ensure that all food is safely stored.
Date to be Corrected: November 28, 2017
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