The inspection was in company of the Facility Manager (Manager), LPN Lead, as well as Christine Jones and Amanda Rose, Licensing Officers in training. The Director of Nursing and the Dietician were both away from the facility at the time of inspection.
The facility is maintained in a clean and sanitary condition with appropriate storage and storage practices throughout. The only exception is that in the main storage area (floor 1) there were some cardboard boxes on the floor. It is recommended that supplies be removed from cardboard boxes since cardboard is not sanitary and that all boxes and supplies be off the floor so it is easy to clean. The Manager advised that this was already addressed.
There was extensive discussion on restraint process and whether policy was implemented. Kaigo forms require a 30, 60, and 90 day assessment for on-going restraints where FH only requires a quarterly update. The 90 day Kaigo assessment was 3 weeks overdue(completed during the inspection) yet a hand-written care plan was in place at 60 days that indicated the requirements for reassessment is quarterly. Also, even though the restraint was checked off as daily on the last FH quarterly update, InterRai did not trigger a restraint care plan. Even though the documentation was somewhat confusing, a determination was made that appropriate care was provided as outlined in the care plan.
It is noted that there are emergency food supplies including water. It is recommended that the menu be reviewed to ensure that the food supplies on hand are consistent with the menu.
The one question not evidenced was related to records kept of on-going education and training of support services staff including dietary. The Food Services Manager advised that there are regular huddles. The Facility Manager indicated that staff now have access to on-line training and that other training programs have been completed. Please confirm with the Dietitian if training was done, how/where the records are kept, and the plan for education for the remainder of the year.
It is requested that a written response be submitted on or before September 12, 2018, describing how the above noted contraventions and/or comments have been appropriately addressed and/or the plan for compliance with legislated requirements. The plan shall include a time line for any items that have not already been addressed. Please note that a follow-up inspection may be conducted to confirm compliance after the written response has been received by Licensing.
Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager.
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