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: The employee performance review checklist showed one of the current employees on their checklist had not had an annual review. This employee was due for a review in June 2017.
Corrective Action(s): Please ensure that employees have regular performance reviews.
Date to be Corrected: Dec 21, 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: Licensing conducted a review of 2 persons in care (PIC) medication administration records for November 2017. It was identified that on the MAR sheets, 2/21 signatures were missing, indicating who administered the medications. Review of the back of the MAR where PRN medications are documented, the column titled "results" was blank for 13/19 medication times administered. Both a staff and the Manager were unsure of the facility policy on documentation for the MAR. After review of the facility policy and the medication advisory safety committee (MSAC) meeting minutes, it was identified that these signatures and "results" column must be completed following administration of the PRN. The manager stated that they are actively working on correcting this as it was previously identified in the routine inspection report dated, February 2015. The manager stated that they have newer staff and she is in the process of training these staff to correct these medication errors from occurring. The MSAC minutes reports that a plan is in place to address these concerns, although this continues to be of concern.
Corrective Action(s): Please ensure all employees comply with the policies and procedures of the medication safety and advisory committee. Please provide further planning on how this will be addressed.
Date to be Corrected: Dec 21 2017
CARE AND/OR SUPERVISION: 34350 - RCR s.63(3)(c)(ii) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (ii) indicated in the care plan of a person in care.
Observation: Review of 1/2 persons care plans and discussion with the Manager, it was identified that a PIC is receiving on-going tray service. There is no information in the care plan to guide staff actions of how to provide on-going tray service to this individual.
Upon Licensing return with the RD (Dietician) on Dec 8 2017, the Manager had started to prepare a care plan which included the on-going tray service. Manager reports that the PIC has been able to join their peers for some mealtimes in the last week. RD recommended adding a chart to indicate whether the PIC was receiving tray service at every meal or if the PIC had returned to previous meal time patterns. Manager stated that the PIC will be supervised while eating at all times. RD requested the updated form to be emailed to her once completed by the Manager. Dietician recommended that on-going tray service is included in the care plan and adjusted as the needs of the PIC change and to ensure that staff are aware of what is required to provide support during meal times.
Corrective Action(s): Please ensure that meals are provided by on-going tray service if indicated in the care plan of a person in care and that staff are aware of these procedures.
Date to be Corrected: Dec 21, 2017
CARE AND/OR SUPERVISION: 34360 - RCR s.63(3)(c)(iii) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iii) approved by the person in care's medical practitioner or nurse practitioner.
Observation: Review of the nutritional assessment done for one person in care indicated that HSCL was concerned that swallowing issues may arise and the PIC should be monitored. In discussion with the manager, it was identified that there was no supervision provided during meal times to this individual. RD and Manager discussed options for the Manager to request the Mental Health clinician to consult on the assessment every 30days as required.
Corrective Action(s): Please ensure that meals are provided by on-going tray service, if approved by the person in cares medical practitioner or nurse practitioner.
Date to be Corrected: Dec 13, 2017
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