Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
22-Aug-2022
Subject
["Neglect","Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Observation: Through the investigation process, Licensing determined that the licensee did not operate the community care facility in a manner that promoted the health, safety and dignity of persons in care. Specifically, wound care documentation was not completed.
Corrective action: Ensure the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care. Specifically, that wound care documentation is completed. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to this contravention. Action/s Required by Licensing: On February 7, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a process for new wounds which included a Wound Care Assessment and Treatment Record and photograph of the wound was to be uploaded in the person in care's chart, an eMAR task was to be generated and assigned to nursing staff for "dressing changes", wound care was to be documented on a Monthly Skin Wound Tracking form, the Care Manager completed a monthly tracking audit of this form, nurses in each neighborhood submitted their list of wounds on a monthly basis, the Skin and Wound Assessment Team (SWAT) were to familiarize themselves with the wounds by following up on a weekly basis, ongoing, and five nurses were enrolled in the SWAT program, started January 2023 and ending June 2023. The corrective action plan was reviewed and accepted by Licensing. On March 1, 2023, Licensing received an email which stated nurses in each neighborhood submitted their list of wounds on a monthly basis, care staff were following up on a wound status weekly, weekly rounds included a review of the existing wound care plans in relations to progression of wound and wound care was documented.