PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Inspection of 5 soiled utility rooms found that 3 were missing countertop molding and in 1 room the molding was only attached at one end and was therefore separated from the countertop causing a potential hazard.
Corrective Action(s): Ensure that all rooms are maintained in a good state of repair.
Date to be Corrected: April 1, 2022
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: Upon inspection of 6 medication rooms, it was observed that 6/6 narcotic books inspected had at least 3 instances since January 1, 2022, whereby a second signature was missing for the administration of a narcotic, or for a narcotic medication count.
Corrective Action(s): Ensure that all employees complies with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: April 1, 2022
CARE AND/OR SUPERVISION: 34160 - RCR s.54(2)(a) - A licensee must (a) assist persons in care to obtain health services as required.
Observation: Upon review of a person in care's (PIC's) records, it was determined that a medical practitioner had ordered a medical test, however the test was not scheduled for 3 days. Of concern is the PIC was without follow-up treatment for that period of time.
Corrective Action(s): Ensure that PICs are assisted in obtaining health services as required.
Date to be Corrected: April 1, 2022
MEDICATION: 36080 - RCR s.69(1)(b) - A licensee must ensure that a pharmacist (b) records all medications on the person in care's medication administration record.
Observation: Upon inspection of a PIC's room, a tube of medicated cream was found. The cream did not have a pharmaceutical label and was not listed on the PIC's medication administration record. Of concern is the application of the cream, the frequency of application, and the potential for a medicinal contraindication, could not be monitored by nursing staff, the pharmacist or the medical practitioner.
Corrective Action(s): Please ensure that medications used by a PIC are recorded on the PIC's medication administration record by a pharmacist.
Date to be Corrected: April 1, 2022
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Upon inspection of 6 medication rooms, there was observed to be expired medication found in the contingency supplies. In discussion with facility staff it was determined that there is a system in place whereby staff, on a monthly basis, inspect the medications and return any medications found to be expiring within the month. The expired medications found during this inspection appear to have been missed.
Corrective Action(s): Ensure that all expired medication is returned to the dispensing pharmacy.
Date to be Corrected: April 1, 2022
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