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:
1). The only shower facility is been out of order and no sign is in place to indicate that the shower was broken. The faucet and the hand held shower piece had water gushing out from most places when tap is turned on. Staff are using the bathtub for all PICs for now.
2). The grab bar in the common shower room is broken and is hanging on upper screws only.
Corrective Action(s): Please ensure that all common areas and amenities are maintained in a good state of repair.
Date to be Corrected: January 15, 2022
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:
1). Narcotic medications count for the month of November had 8 missing signatures for the counter signing nurse.
2). Medication administration Records (MAR) of 2/5 PICs did not have effectiveness of the PRN medication documented twice in July, 2021.
Corrective Action(s): Please ensure that staff comply with the policies of MSAC.
Date to be Corrected: December 31, 2021.
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:
1). 3/5 PICs' admission checklists were not completed appropriately. It had missing signatures and blank spaces on the checklist were found. Upon discussion with the staff assisting with the inspection LO noted that the recent outbreak at the facility had led to staffing constraints and some documents were not fully completed. The staff will do chart audits and update the documents.
2). Review of 4/5 PICs' charts found that Addressographs were not placed by staff on progress notes sheets, admission checklists, neurovital assessments sheets and other documents. Most of these documents had only the name of the PIC (hand written) instead of the Addressograph.
3). 2 PICs admitted in November had missing weights and heights and LO was informed that during the outbreak staff were not completing these tasks. All heights and weights will be reviewed by staff and completed.
Corrective Action(s): Please ensure that all policies are implemented by employees.
Date to be Corrected: December 31, 2021
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:
1/5 PICs' wound care plan was changed in August to include "shower only, not to use the bathtub" however, the care plan and the bath plan instructions for care staff were not revised.
Corrective Action(s): Please ensure that the implementation of each care plan is monitored and involved staff updated on regular basis to ensure proper implementation.
Date to be Corrected: December 31, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation:
A comb with no identifier was observed in the tub room. 27/56 nail clippers were missing from the clipper drawers in the cupboard. 1 clipper drawer had 2 nail clippers. The staff assisting with the inspection informed the LO that some nail clippers were stored in the bedrooms but will be brought back to the nail clipper drawers in the tub room.
Corrective Action(s): Please ensure that items intended for personal use (to ensure health and hygiene) are not available to others.
Date to be Corrected: December 31, 2021
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 fridge and freezer temperature in the resident fridge in the conference room had no temperature logged since October, 2021. The fridge is used to store resident food items at present. The staff person assisting with the inspection informed LO that the new thermometer was going to be ordered this week.
Corrective Action(s): Please ensure that all food is safely stored, served and handled by staff and ensuring temperatures logged appropriately.
Date to be Corrected: December 31, 2021
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