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: A random review of the hot water temperature at ensuite washroom sinks gave the following readings:
* 54.5 degrees Celsius
* 54.2 degrees Celsius
Corrective Action(s): Please ensure water accessible to a person in care from any source is not heated to more than 49 degrees Celsius. On June 4, 2022, the Manager put in a maintenance request to address the hot water temperature.
Date to be Corrected: June 4, 2022.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31200 - RCR s.19(3) - If a licensee installs electronic devices for the purposes of transmitting or recording images of persons in care or members of the public, the licensee must display in a prominent place notice that electronic surveillance is being used.
Observation: The facility has video cameras and currently there is no signage posted indicating that there is video surveillance.
Corrective Action(s): Please ensure signage is displayed in a prominent place that electronic surveillance is being used.
Date to be Corrected: July 22, 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: In review of the hospice documentation regarding the following were observed, for example:
- Opiod PRN (as needed) medication administration records, the "evaluation" section for some medications did not have a result/outcome. Specifics of where the gaps were noted, were provided at the time of the inspection.
- Medication Administration Records had dates medication(s) were administered and no staff initials documented. Specifics of where the gaps were noted, were provided at the time of the inspection.
In review of the long term component documentation there were also in various locations of the medication administration records for PRN (as needed) medications with no result/outcome noted. Specifics were provided at the time of the inspection.
Corrective Action(s): Please ensure all staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: June 17, 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: In review of the documentation for hospice, there was a person in care's record that did not have information documented for the kardex. Specifics were provided at the time of the inspection.
In review of the documentation for long term care, the post fall documentation on page 2 had information not documented (e.g., Was ambulance called)(Words to this effect). Specifics were provided at the time of the inspection.
Corrective Action(s): Please ensure all staff implement the applicable policies such as the "charting" policy.
Date to be Corrected: June 17, 2022.
MEDICATION: 36130 - RCR s.70(4)(a) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (a) approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Observation: Please refer to section 70 (4)(b) of the Residential Care Regulation.
Corrective Action(s): As above.
Date to be Corrected: June 17, 2022.
MEDICATION: 36140 - RCR s.70(4)(b) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (b) included in the care plan of the person in care.
Observation: In review of the documentation and in discussion with the Hospice staff, there is a person in care who is self medicating with the medication at the bedside, however this is not noted in the person in care's care plan and there is no indication this was reviewed (and approved) with the Medication Safety and Advisory Committee and reviewed with the Medical Practitioner.
Corrective Action(s): Please ensure a person in care who self adminsters medication(s), that the Medication Safety and Advisory Committee has approved this and the Medical Practitioner is involved. Finally, please include the plan for self medication administration in the person in care's care plan.
Date to be Corrected: June 17, 2022.
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: There is no formal substitution list that was available for review during the inspection.
Corrective Action(s): Please ensure a record of the substitutions to the menu is kept.
Date to be Corrected: June 10, 2022.
|