PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: 3 water temperatures were taken and 1/3 was over the maximum level at 53 degrees. The sink was located close to the nursing station on main north.
Corrective Action(s): Ensure that water accessible to PIC's from all sources is not heated to more than 49 degrees.
Date to be Corrected: June 30, 2016
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31160 - RCR s.19(1)(c) - If a person in care requires monitoring, or a signalling device, to ensure that person's health and safety, a licensee must provide a monitoring system or signalling device that (c) will signal to employees that the person in care needs immediate assistance.
Observation: Call bell records for one unit from May 16-22 2016 were reviewed by the LO. The DOC provided a Call Bell Management policy as requested by the January 2016 routine inspection. There were 558 calls activated in this time period. Of those, 41 calls were not answered within the 5-10 minutes outlined in the policy.
11 calls from 10-11 minutes
22 calls from 11-15 minutes
3 calls from 15-29 minutes
5 calls over 29 minutes
Although 41 calls were out of the range in the policy, this does reflect an improvement from the January 2016 routine inspection.
Corrective Action(s): Ensure that monitoring equipment is used according to the facility policy
Date to be Corrected: June 30,2016
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: It was observed in several areas of the building that several cupboard doors were missing, and melamine type cupboard and counter surfaces were absent or broken. The absence of melamine surface makes sanitizing unlikely.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair
Date to be Corrected: June 30, 2016
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: The backsplash for the medication room sink in lower north has blackened deteriorating caulking, and the backsplash behind the SCU dining room sink is also deteriorated and is missing areas of caulking. These areas cannot be sanitized in their current state.
Corrective Action(s): Ensure that all rooms and common areas are inspected and maintained on a regular basis.
Date to be Corrected: June 30, 2016
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31610 - RCR s.30(d) - A licensee must ensure that all bathrooms have (d) any other equipment that is necessary to protect the health, safety and dignity of the persons in care.
Observation: Bathrooms throughout the facility were observed to be cluttered with equipment and supplies. ADL lists that are used to document bath times showed several PIC's only had 3 documented bath times per month, with no documentation as to why the missed bathing occured. Staff reported that when bathing does not occur, a reason should be documented. The DOC reports that the issue of storage areas is being discussed by the management team.
Corrective Action(s): Provide a sustainable plan for facility storage that will allow the PIC's the dignity and enjoyment of the bathing experience without the clutter contained in the bathing area.
Date to be Corrected: June 30, 2016
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Performance reviews are in progress but not up to date as of yet. An action plan has been provided to CCFL to complete all reviews by the end of the year.
Corrective Action(s): Ensure that performance is reviewed regularly
Date to be Corrected:
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: A new policy around monitoring after falls has been created and implemented by the DOC, but this is not being completed consistently. The DOC reports that education to ensure all staff complete the assessments according to policy is ongoing.
Corrective Action(s): Ensure all staff follow facility policies
Date to be Corrected: June 30, 2016
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: HR has sent out a request to all staff who have not submitted immunization and TB information, and is in the process of collecting them. This is in process and has not been completed yet.
Corrective Action(s): Ensure that all employees provide evidence of continued compliance with the province's immunization and TB control programs
Date to be Corrected: July 31, 2016
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Currently the facility is working on gathering all of the immunization and TB records for all PIC who do not have them. This is in progress and is incomplete at the time of the inspection.
Corrective Action(s): Ensure that all PIC's have evidence of compliance with the province's immunization and TB control programs.
Date to be Corrected: July 31, 2016
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: The main north fridge temperature was 8.5 degrees and the freezer was -10 degrees. This fridge was observed to currently be storing food. The safe fridge temperature for food storage is 0-4 degrees and for freezers is -18 to -22 degrees. No regular temperature monitoring for this fridge/freezer was found.
Corrective Action(s): Please ensure that all cooling devices for food storage are monitored regularly and are kept within safe temperature ranges.
Date to be Corrected: June 30,2016
RECORDS AND REPORTING: 39280 - RCR s.79(2) - A licensee must issue or get a receipt, as applicable, for the matters described in subsection (1).
Observation: A new policy and process for safe storage and handling of PIC valuables was reviewed by the LO. At this time the process has not been implemented and education and implementation of the process is expected in June 2016.
Corrective Action(s): Ensure that a process is in place for PIC valuables.
Date to be Corrected: June 30, 2016
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