CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Although the care plan has been reviewed/revised within the last year, there are components of the care plan that do not show a review date and have a date in excess of one year. For example the ADL routine, ADL bedtime and meal guidelines do not have a review date which makes it difficult to determine if the plan is current.
Corrective Action(s): Ensure all components of the care plan show a review or revision date.
Date to be Corrected:
MEDICATION: 36100 - RCR s.70(1) - A licensee must ensure that only medications that have been prescribed or ordered by a medical practitioner or nurse practitioner are administered to a person in care.
Observation: In review of the documentation for 1 resident, it appeared that there were 3-4 treatments in which the MAR showed a date that the prescription was valid to. However, these dates have passed by approximately 2 months. Likewise there was a tag/label on the treatment containers that also showed a "good to" date. It therefore appears there is not a current prescription for the medications. At the time of this inspection, the most recent medication review for the resident could not be located to confirm if the prescriptions were current.
Corrective Action(s): Ensure there is an effective system in place that provides clarity as to if there is a current prescription to administer medication/treatments.
Date to be Corrected:
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