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: Medication Administration Records (MAR) for one month were reviewed for 19 persons in care. The follow up response assessing the effectiveness of all medications administered as needed (PRN) were not completed as required for 16 persons in care.
Corrective Action(s): Please ensure staff implement policies regarding medication administration as required.
Date to be Corrected: December 6, 2023
CARE AND/OR SUPERVISION: 34470 - RCR s.73(2)(c) - In addition to the requirements under subsection 73(1), the following conditions apply to the use of a restraint under section 74(1)(b) [when restraints may be used]: (c) the use of the restraint, its type and the duration for which it is used must be documented in the care plan of the person in care.
Observation: A person in care had a care plan developed for only one of the two restraints in use.
Corrective Action(s): Please ensure that all restraints in use have a care plan developed.
Date to be Corrected: December 6, 2023
CARE AND/OR SUPERVISION: 34710 - RCR s.81(3)(f)(ii) - A care plan must include all of the following: (f) if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan (ii) if the person in care leaves without notification, to locate the person in care.
Observation: Two persons in care who had been assessed and identified as at risk for elopement from the facility had care plans related to preventing their elopement, however they did not include a plan to locate them if their elopement was successful.
Corrective Action(s): Please ensure to include a location plan.
Date to be Corrected: December 6, 2023
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: Five of the six person in care records that were reviewed, did not contain all the required documentation to confirm compliance with the Province's immunization and/or tuberculosis control programs.
Corrective Action(s): Please ensure all persons in care comply with the Province's program for immunization and TB control.
Date to be Corrected: December 6, 2023
RECORDS AND REPORTING: 39200 - RCR s.78(2)(b) - A licensee must keep, for each person in care, a medication administration record showing (b) the date, amount and time at which the medication was administered.
Observation: The Medication Administration Records (MAR) for 19 persons in care for the current month were reviewed and it was noted that 11 PICs had incomplete records as staff had not signed for all medications that were administered.
Corrective Action(s): Please ensure MAR documentation is complete as required for all persons in care.
Date to be Corrected: December 6, 2023
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