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: In a review of the Medication Administration Records (MAR) for four persons in care (PIC) it was observed that on two occasions staff made changes to medication orders for two PICs. Once was a medication and the second was the dose of a medication, in both cases the orders were to have been new orders, and the original order documented as either discontinued or changed.
Corrective Action(s): Please ensure staff comply with the policies related to medication and documentation.
Date to be Corrected: July 14, 2022
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: A person in care had changes made to a medication protocol that is part of their care plan, however the changes had not yet been updated in record made available for staff to review. [CORRECTED prior to completion of inspection.]
Corrective Action(s): Please ensure that if changes to a PIC's care plan are required, that their care plan is updated.
Date to be Corrected: July 14, 2022
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: In a review of the 4 week menu and in speaking with staff it was confirmed only one snack was provided to persons in care.
Corrective Action(s): Please ensure that your menu includes two snacks each day.
Date to be Corrected: July 14, 2022
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: In a review of the menu and food serving audit it was confirmed that the menu developed did not ensure the daily minimum requirements for each food group each day.
Corrective Action(s): Please ensure the menu developed meets the minimum requirements for each food group each day.
Date to be Corrected: July 17, 2022
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: The audits for the 4 week cycle menu were incomplete, missing Part B of the assessment.
Corrective Action(s): Please ensure that records of monitoring are complete
Date to be Corrected: July 14, 2022
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