PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Chemical cleaners that could be hazardous were found stored below the sinks in two areas of the facility and left accessible to persons in care.
Corrective Action(s): Please ensure hazardous materials are stored in a safe and secure manner.
Date to be Corrected: August 19, 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: Medications administered on a PRN basis must have the reason for the medication, the minimum interval of time between doses and the maximum number of daily doses recorded on the PICs Medication Administration Record (MAR) and on the package of medication. The MAR must include the name of all drugs being administered.
When reviewing the MARs and packaged medications for four PICs the following was observed for PRN medication:
- Some did not include the minimum interval of time between doses
- Some did not include the maximum numbers of doses in a day
- Some did not include the reason for administering the medication
- One medication did not include the name of the drug to be administered
Corrective Action(s): Please ensure policies and procedures are implemented
Date to be Corrected: August 19, 2022
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: As per the Licensee's policy, staff are to document the effectiveness of any PRN medication administered to a PIC and in a review of medication administration to a PIC over three days, documentation of effectiveness did not occur after they received a PRN medication.
Corrective Action(s): Please ensure staff implement the policy and document the effectiveness of PRN medication administered to PICs.
Date to be Corrected: August 19, 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: The care plan for PICs must include a plan to address their medication needs. The PRN protocol for one PIC was different when compared to the practitioners order that was recorded on the PICs MAR.
Corrective Action(s): Please ensure care plans are modified when changes occur in the needs of the PIC.
Date to be Corrected: August 19, 2022
MEDICATION: 36090 - RCR s.69(2) - A licensee must ensure that, except as authorized by the medication safety and advisory committee, a person in care's medications remain in the original labelled container or package provided by the dispensing pharmacy until administered.
Observation: During the inspection, five medications were found removed from their original packaging as dispensed by the pharmacy and put into envelopes with a handwritten descriptions.
Corrective Action(s): Unless authorized by the MSAC, staff must ensure the PICs medications remain in their original labelled packaging as provided by the pharmacy.
Date to be Corrected: August 19, 2022
MEDICATION: 36160 - RCR s.72(a) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (a) the person in care is no longer taking the medication.
Observation: The medications and Medication Administration Records (MAR) for four PICs were reviewed and it was confirmed that staff did not remove and return to pharmacy four medications that were no longer required.
Corrective Action(s): Please ensure all medication no longer required are returned to the dispensing pharmacy.
Date to be Corrected: August 19, 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: During the inspection, the expiration dates on all medications available for administration for four PIC were reviewed and the following was noted:
- Four medications were expired
- A ointment had been opened and not dated, unable to confirm medication was not expired
- A ointment had been opened and the expiration date changed. Original date indicated medication was expired and so could not confirm medication was not expired.
Corrective Action(s): Please ensure expired medication is returned to pharmacy
Date to be Corrected: August 19, 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 review of the four week menu cycle and in speaking with staff, it was confirmed that one of the two snacks provided to PIC consisted of one food group instead of two food group as required.
Corrective Action(s): Please ensure that each snack provided consists of at least two different food groups.
Date to be Corrected: August 19, 2022
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