Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
23-Mar-2023
Subject
["Emotional Abuse","Suitability of Manager or Suitability of Licensee","Staffing (Includes issues such as suitability, insufficient levels, etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
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 investigation process, Licensing determined that the licensee did not immediately notify a medical health officer of a reportable incident that involved a person in care, in the form and in the manner required by the medical health officer.
Corrective action: Ensure that if a person in care is involved in a reportable incident, that the medical health officer is immediately notified, 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 May 12, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that incident reporting education was provided by the Licensing program, to staff, on May 24, 2023. The corrective action plan was reviewed and accepted by Licensing. On May 24, 2023, the Licensing program provided education to staff on incident reporting.
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 investigation process, Licensing determined that the Licensee did not ensure to operate the community care facility in a manner that promoted the health, safety, and dignity of persons in care.
Corrective action: Ensure to operate the community care facility in a manner that will promote the health, safety, and dignity of persons 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 May 12, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: the manager would complete leadership training by May 18, 2023, a clear protocol was to be developed regarding communication with management, and the Manager to meet with Leadership Team to discuss offloading errands and appointments to ensure they were more present at the facility. The corrective action plan was reviewed and accepted by Licensing. On September 13, 2023, Licensing was informed that the staff was no longer the Manager at the facility.
A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care
Observation: Through the investigation process, Licensing determined that the Licensee did not ensure to keep a medication administration record showing all medications administered to a person in care.
Corrective action: Ensure to keep for each person in care, a medication administration record showing all medications administered to 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 May 12, 2023, Licensee submitted a corrective action plan. The corrective action plan included that only employees would administer medications, and the visitor was directed to not administer medications to persons in care while at the facility. The corrective action plan was reviewed and accepted by Licensing. On September 13, 2023, Licensing was notified that the visitor had not administered any medications and all medications were administered by employees.
A licensee must ensure that a person in care is not, while under the care or supervision of the licensee subjected to any of the following types of abuse or neglect, as described in section 1 of Schedule D: emotional abuse
Observation: Through the investigation process, Licensing determined that the Licensee did not ensure that a person in care is not, while under the care or supervision of the Licensee, subjected to emotional abuse.
Corrective action: Ensure that a person in care is not, while under the care or supervision of the Licensee, subjected to emotional abuse. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 12, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included the management staff would review their abuse and neglect policy to ensure the policy was up to date, and the Manager and Licensee would draft a presentation of the policy to visitors by June 7, 2023. The corrective action plan was reviewed and accepted by Licensing. On September 13, 2023 Licensing was notified that the abuse and neglect policy had been reviewed and updated.
Subject to subsection (4), a licensee must ensure that only employees administer medications to a person in care,
Observation: Through the investigation process, Licensing determine that the Licensee did not ensure that only employees administered medications to a person in care.
Corrective action: Ensure that only employees administer medications to a person in care. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On May 12, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included, the visitor was directed to not administer medications to a person in care and the Manager was trained to administer an injectable medication. The corrective action plan was reviewed and accepted by Licensing. On September 13, 2023, Licensing was notified that the visitor had not administered any medications and all medications were administered by employees.