LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: During this inspection there were contraventions related to the documentation and monitoring of care for example: The Diet/Food Allergies and Dislikes list posted in the kitchen area is used as communication tool to link the information from the nutrition care plan to the foodservices. The list was last updated in June 2016 and does not include one PIC who has been diagnosed with diabetes, housekeeping audits are not completed as per policy, policies have been reviewed annually however, forms have not been updated to the forms currently being used by staff, required information is missing from recovery plans. The appointed Manager was also unfamiliar with some of the requirements of Managing a licensed facility.
Corrective Action(s): Licensing discussed with the Manager and the Licensee contact the importance of implementing self-monitoring systems to ensure ongoing compliance to legislation is maintained and the health & safety of persons in care is ensured. Licensing is requesting that the compliance plan includes information as to how the Licensee will ensure monitoring is completed.
Date to be Corrected: July 14, 2017
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Two bathrooms located in the main hall used by persons in care the following was observed: the tile flooring and base boards had a build up of black dirt around the edges. On one bathtub where the floor tile and front of the tub meet the grout/caulking was chipped away, some tiles were cracked and the bathtub wall had a build up of white residue. The second bathtub, as explained by the Manager was new. The Manager explained staff are assigned to clean the bathroom, upon review of the 'Housekeeping" policy there is reference to a "checklist" to be used by staff, however, the Manager was not aware of an audit system in place to ensure staff tasks are completed as required.
Corrective Action(s): Please ensure common areas are maintained in a clean manner and that self-monitoring systems are in place.
Date to be Corrected: July 10, 2017
CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: Review of 3 person in care's dental appointment records 2 of the 3 records document the person in care's last appointment being in 2015 and no further documentation was found to confirm if they had been encouraged and/or had an appointment with a dentist.
Corrective Action(s): Please ensure persons in care are supported to obtain dental services.
Date to be Corrected: July 14, 2017 please include your compliance plan
CARE AND/OR SUPERVISION: 34210 - RCR s.54(3)(b)(iii) - A licensee must (b) assist persons in care to (iii) follow a recommendation or order for dental treatment made by a dental health care professional.
Observation: One of three persons in care documented in the nursing notes that he required dental extractions in November 2015, however there was no evidence found that he attended the appointment. The Manager was unable to confirm if the person in care attended the required appointment.
Corrective Action(s): Please ensure documentation is maintained to confirm persons in care are supported to attend required appointments.
Date to be Corrected: July 14, 2017 - incude compliance with your complaince plan/written response
CARE AND/OR SUPERVISION: 34650 - RCR s.81(3)(c)(ii) - A care plan must include all of the following: (c) a nutrition plan that (ii) specifies the nutrition to be provided to the person in care, including the requirements of any therapeutic diets.
Observation: The Manager explained for one person in care his meals and quantity served are adjusted to support his health condition, however the strategies were not documented in his recovery plan and/or any other nutritional records but rather communicated verbally to the cook. This is of concern as it could impact on the continuity of care if different staff assess his condition differently.
Corrective Action(s): To ensure continuity and safe care is provided please ensure specific strategies to support person in care's therapeutic diet is documented and available to staff.
Date to be Corrected: July 14, 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: Upon review of 3 person in care's records and discussion with the Manager there was no documentation available to confirm persons in care's activity/recreation goals have been met. Although there is an activity schedule and persons in care sign up on the board, their attendance and/or participation is not documented and/or tracked. For example 1 person in care had a goal to attend a specific activity in community 3x per week and there was no evidence available to confirm this occurred.
Corrective Action(s): Please ensure all areas of the recovery plan are monitored to ensure they are implemented accordingly.
Date to be Corrected: July 14,2017
CARE AND/OR SUPERVISION: 34840 - RCR s.83(3)(a) - A licensee must review the nutrition plan of a person in care as follows: (a) in the case of a nutrition plan developed under subsection (1), on a regular basis.
Observation: A random audit of 3 persons in care nutrition care plans was completed and some components of the plan have not been reviewed since 2015. The facility uses, as per their policy, forms from the Meals and More resource to support staff in completing nutritional assessments and planning. Although a screening form to determine risk level and a need to refer to a dietitian was completed, thee "Food and Nutrition Information" form was last reviewed in June 2015 and one person in care's nutritional status had changed substantially since 2015. In addition, weight records reviewed documented monthly weights being obtained however review of the weight ranges in correlation to the goal body weight the calculations did not match. It appeared that although there were changes in body weight, staff just transferred the information from the years previous.
Corrective Action(s): Please ensure all components of the assessment and care/recovery planning is reviewed to ensure the current status of persons in care is accurately reflected.
Date to be Corrected: July 14, 2017
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: Two persons in care self-administer medication, however, review of their records indicated the last approval date being 2010 and 2007. Review of the pharmacy policy there is a consent form and a procedure to follow for monitoring the self-administration. There was no evidence of the signed pharmacy consent form and or monitoring as per the policy.
Corrective Action(s): Please ensure policy is followed in respect to self administration and consent is obtained.
Date to be Corrected: July 14, 2017
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Review of the facility internal incident log book, 3 person in care's nursing notes, and discussion with the Manager there were 3 different persons in care that have required transfer to hospital (April & Oct, 2016) and most recently in June 2017, however the incidents were not reported to Licensing as required. Licensing also observed internal incidents being documented on the Fraser Health provided triplicate forms and recommends only using these forms for documenting incidents reportable to Licensing.
Corrective Action(s): Licensing explained the requirements for reporting incidents with the Manager, please ensure all incidents reportable to Licensing are submitted in the timelines required (ie. urgent/serious incidents within 24). The facility instruction sheet for incident reporting was provided as a resource.
Date to be Corrected: June 30, 2017
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