POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: A random audit of 8 PIC charts were reviewed. It was noted that in two of the charts that the flow sheets had been documented that side rails were used for one of PIC for the month of Nov 2017 and Feb 2018 and the other PIC side rails were used in Jan 2018. There was no written documentation to support the use of restraints by the medical practitioner nor family representative for these two individuals..
Corrective Action(s): Ensure written documentation is obtained to support the use of restraints by the medical practitioner and family representative prior to use.
Date to be Corrected: Please submit a compliance plan by April 12th, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: It was observed in all dining rooms that juices were not dated and labelled in fridges. Food was also stored in bus bins on the floor in the walk in freezer and fridge in the main kitchen.
Corrective Action(s): Ensure food is up off the floor and all food/liquids are dated and labelled appropriately.
Date to be Corrected: Please submit a compliance plan by April 12th, 2018.
RECORDS AND REPORTING: 39370 - RCR s.84(d) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (d) the duration of the restraint and the monitoring of the person in care during the restraint.
Observation: For two PIC the restraint monitoring flow sheets did not identify the length of time the restraint was applied and/or removed. In discussion with the DOC the repositioning is not being captured on the flow sheets.
Corrective Action(s): Ensure monitoring is consistent and plan is current with all applicable information to ensure consistency in care is provided.
Date to be Corrected: Please submit a compliance plan by April 12th, 2018
|