PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Inspection of one bedroom found a large hole in the right side of the window sill.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: November 25, 2019
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Review of the staffing checklist determined that four staff were overdue for their regular performance review.
Corrective Action(s): Ensure that each employee is reviewed regularly to ensure that the employee continues to meet the requirements of the regulation.
Date to be Corrected: November 25, 2019
STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: Review of the emergency plan documentation determined that staff had not completed an emergency drill at the facility since July 2019.
Corrective Action(s): Ensure that each employee is trained in the implementation of the plans including the use of any equipment noted in the plan.
Date to be Corrected: November 25, 2019
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 (CORRECTED DURING INSPECTION): Review of the MAR determined that two medications had not been initialed as administered and were left blank. Inspection of the medication storage found the medication for one date was labelled refused and discussion with staff determined that both medications had been refused. Review of the MSAC policies determined that medications need to be marked with a number in the MAR if they are refused and not left blank on the MAR sheet.
Corrective Action(s): Ensure that staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: CORRECTED DURING INSPECTION
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: Review of the persons in care (PIC) financial records determined that they had not been reconciled since August 2019. Discussion with staff determined that PIC financial records are to be reconciled monthly.
Corrective Action(s): Ensure that policies are implemented by employees.
Date to be Corrected: November 25, 2019
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: Review of two of four person in care (PIC) care plans determined that one PIC has had recent significant changes in their care plan and this is not captured in the current care plan documentation.
Corrective Action(s): Ensue that all records are modified if there is a substantial change in the circumstances of the person in care.
Date to be Corrected: November 25, 2019
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: Review of two persons in care (PIC) care plans found that nutrition documentation for the two PIC's was last updated in January 2017. One persons in care (PIC) nutrition care plan was last updated in May 2019 but there had been significant changes within the last month that were not captured.
Corrective Action(s): Ensure that care plans are updated to meet the needs and preferences of the persons in care.
Date to be Corrected: November 25, 2019
MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: Review of documentation and discussion with staff determined that the supervising pharmacist had not inspected the medication storage since 2018. Staff confirmed that the pharmacist was expected within the next two months.
Corrective Action(s): Ensure that the supervision pharmacist regularly inspect the medication storage area.
Date to be Corrected: November 25, 2019
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: Review of the medication storage found one over-the-counter medications and one topical medication that were not labelled by the pharmacist.
Corrective Action(s): Ensure that the pharmacist packages all medications
Date to be Corrected: November 25, 2019
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: Review of two persons in care (PIC) care plans found that one PIC was missing 3 monthly weights and one PIC was missing 5 monthly weights.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: November 25, 2019
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