PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31090 - RCR s.16(3) - A licensee must ensure that the lighting, both natural and artificial, and temperature of a room intended for the private use of a person in care meets the needs and preferences of that person.
Observation: During review of the Policies ad Procedures, kept in the back door hallway it was noticed that the lighting was very low. It was not bright enough to accommodate the review of the documents stored in this area.
The LO entered a room with a PIC present, the lighting was dim and the lens was missing from the fixture leaving the bulbs exposed to the risk of breakage. New lifts had been installed in the ceiling and the lens would catch on the ceiling lift beam as it moved across the room when in use. the lens was missing from an under cupboard florescent, horizontally mounted above the counter to the left of the fridge. This leaves the florescent tube exposed to potential breakage in a food preparation area.
Corrective Action(s): Please provide a plan to ensure that all lighting issues will be addressed to ensure safe lighting levels for the use of staff and residents in their activities.
Date to be Corrected: Nov. 8, 2017
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: The cupboard for hazardous materials straddles between the laundry room and the tub room. On the tub room side, the is a small access door that is not secured
Corrective Action(s): Please provide a plan that will ensure that all hazardous products are securely stored.
Date to be Corrected: Nov. 8, 2017
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: Performance reviews of staff are not observed to be conducted annually as per the policy.
Corrective Action(s): Please provide a plan that will ensure that there is consistency with the policy and the practice of conducting performance reviews.
Date to be Corrected: Nov. 8, 2017
POLICIES AND PROCEDURES: 33320 - RCR s.85(2)(b) - Without limiting subsection (1)(a), a licensee must have written policies and procedures in respect of all of the following: (b) the orientation of new managers and employees, including orientation respecting the policies and procedures of the community care facility, the regulations and the Act.
Observation: Policy for orientation of managers and employees to the regulations and the act revealed expectations for the manager orientation but no expectation of familiarity with the legislation for employees.
Corrective Action(s): Please provide a plan that will ensure that the intent of the above legislation is complied with.
Date to be Corrected: Nov. 8, 2017
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: A PIC was observed sitting in a "veil bed" in a dark room. the PIC was described as receiving some "stretch time and had just been given 'bowel therapy.' The care plan for this individual described 45 minutes per day of floor time. the manager stated this was not being done at present due to the presence of another new ambulatory resident and there was concern about how the two individuals would interact during 'floor time'. There was no indication in the care plan that the floor time should be discontinued.
Corrective Action(s): Please provide a plan that will ensure that the direction in the care plan is followed or revised.
Date to be Corrected: Nov. 8, 2017
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Weights for all PICs were observed to be absent after April 2017. There was no reason for the absence of weight record provided in the documentation. The manager states that the weigh scale has been broken since April. BC Housing was notified. Six months without weights for the residents is far to long, as this is a significant component of monitoring the nutritional status of the persons in care (PICs)
Corrective Action(s): In the event that weights cannot be achieved on site, the Licensee is responsible to determine an alternative means to meeting the intent of the legislation.
Please provide a plan to ensure that appropriate monitoring of the weight of each PIC occurs on a consistent basis as determined by the regulation.
Date to be Corrected: Nov. 8, 2017
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