Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
19-Oct-2021
Subject
["Restraints"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: Through the Licensing investigation process, Licensing determined that there was no signed agreement form by a person in care's medical or nurse practitioner to use restraint on person in care available.
Corrective action: Ensure that an agreement for the use of a restraint was given in writing by both the medical practitioner or nurse practitioner responsible for the health of the person in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On October 22 and December 30, 2021, Licensee submitted a corrective action plan. The corrective action plan included: On January 17, 2022, a process was to be implemented to ensure persons in care's restraint agreement forms were completed and filed. Persons in care who required Risk Agreements for restraint use was completed. The corrective action plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection required. On April 11, 2022, Licensing received an agenda for the Practice Council Meeting which included education Managed Risk Agreements and confirmation via email stating that Managed Risk Agreements for persons in care requiring restraints were completed.
To be corrected by: 11-Apr-2022
A licensee must ensure that a restraint is not used unless the safety and physical and emotional dignity of the person in care is monitored throughout the use of the restraint, and assessed after the use of the restraint.
Observation: Through the Licensing investigation process, Licensing determined that a restraint was used on a person in care that jeopardized the safety and physical and emotional dignity of the person in care without monitoring throughout the use of restraint, and not assessed after the use of the restraint.
Corrective action: Ensure restraints were not used unless the safety and physical and emotional dignity of the person in care was monitored throughout the use of the restraint, and assessed after the use of the restraint. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On October 22 and December 30, 2021, Licensee submitted a corrective action plan. The corrective action plan included one on one education for the staff in regards to restraints, by Health Care Aide Lead; between October 29 and November 4, 2021, all Health Care Aides will be provided education on Least Restraint Park Place Seniors Living I-Learn Module, and Least Restraint Policies. The corrective action plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection required. On January 17 and April 11, 2022, Licensing received an email and documentation, that indicated staff had attended the Practice Council Meeting, which included education on least restraint, monitoring restraint, and least restraint policies and procedures on November 3 and 4, 2021. The staff was provided one on one education from the Care Health Care Aide Lead.
To be corrected by: 11-Apr-2022
Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer
Observation: Through the Licensing investigation process Licensing determined that the Licensee did not immediately notify Licensing when a person in care was involved in a reportable incident.
Corrective action: Ensure if a person in care was involved in a reportable incident, the licensee must immediately notify the medical health officer, in the form and in the manner required by the medical health officer. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On October 22 and December 30, 2021, Licensee submitted a corrective action plan. The corrective action plan included on January 17, 2022 nurses would receive education related to incident reporting. The corrective action plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection required. On April 11, 2022, Licensing received the agenda for the Practice Council meeting indicating education was provided to nurses incident reporting.
A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.
Observation: Through the Licensing investigation process, Licensing determined that the staff did not ensure the care and supervision of a person in care was consistent with the terms and conditions of the person in care's care plan specifically the usage of restraint on person in care.
Corrective action: Ensure that the care and supervision of a person in care was consistent with the terms and conditions of the person in care's care plan. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On October 22 and December 30, 2021, Licensee submitted a corrective action plan. The corrective action plan included education will be provided to the staff, in regards to restraints, including one on one training by Health Care Aide Lead, completion of Least Restraint Park Place Seniors Living I-Learn Module, and review of Least Restraint Policies. On January 17 and April 11, 2022, Licensing received an email and documentation, that indicated staff attended the Practice Council meeting, which included education on least restraint, monitoring restraint, and least restraint policies and procedures on November 3 and 4, 2021. The staff was provided one on one education from the Health Care Lead.
A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Observation: Through the Licensing investigation process, Licensing determined that the Licensee had not ensured that the facility was operated in a manner that would promote the health, safety, and dignity of persons in care, specifically to staff's character and skills.
Corrective action: Ensure that the community care facility was operated in a manner that would promote the health, safety, dignity of persons in care, specifically staff's character and skills. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On October 22 and December 30, 2021, Licensee submitted a corrective action plan. The corrective action plan included staff would receive education, including one on one restraints training by Health Care Aide Lead, complete the Resident Centred Manual, Least Restraint Park Place Seniors Living I-Learn Module, and review of Least Restraint policies. The corrective action plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection required. On January 17 and April 11, 2022, Licensing received an email and documentation, that indicated that staff attended the Practice Council meeting dated January 7, 2022, which included education around least restraint, monitoring restraint, and least restraint policies and procedures on November 3 and 4, 2021. The staff was provided one on one education from the Health Care Aide Lead.
To be corrected by: 11-Apr-2022
Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care,
Observation: Through the Licensing investigation process, Licensing determined that there was no signed agreement form by a representative to use restraint on person in care.
Corrective action: Ensure that an agreement for the use of a restraint was given in writing by both the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On October 22 and December 30, 2021, Licensee submitted a corrective action plan. The corrective action plan included: On January 17, 2022, a process to be implemented to ensure persons in care's restraint agreement forms were completed and filed. Persons in care who required Risk Agreements for restraint use was completed. The corrective action plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection required. On April 11, 2022, Licensing received an agenda for the Practice Council Meeting which included education Managed Risk Agreements and confirmation via email stating that Managed Risk Agreements for persons in care requiring restraints were completed.
To be corrected by: 11-Apr-2022