Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
09-Nov-2022
Subject
["Recordkeeping (Includes issues such as not keeping records, insufficient records, care planning issues, health care consent, admission records.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
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: neglect
Observation: Through the investigation process, Licensing determined that staff had subjected a person in care to neglect. Specifically, a person in care was not fed breakfast by staff.
Corrective action: Ensure that a person in care is not, while under the care and supervision of the licensee, subjected to neglect. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 18 and 22, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: by December 25, 2022, a task for meal assistance was developed in Point of Care (POC) for staff to complete and by January 15, 2023, all regular Licensed Practical Nurses (LPNs) were to review the abuse and neglect policy. This corrective action plan was reviewed and accepted by Licensing. On February 9, 2023, Licensing received POC documentation which indicated that the person in care had received meals and a letter which stated the abuse and neglect policy had been reviewed by staff.
A licensee must ensure that meals are provided by ongoing room tray service, if approved by the person in care’s medical practitioner or nurse practitioner
Observation: Through the investigation process, Licensing determined that a person in care received tray service which had not been approved by their medical practitioner.
Corrective action: Ensure that if meals are provided by ongoing tray service, that it is approved by the person in care's medical or nurse practitioner. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 18 and 22, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: by December 25, 2022, a person in care was to receive an order for tray service from their physician and an audit was to be conducted by January 15, 2023, on person in care's charts who received tray service, to ensure they all had orders for tray service from their medical or nurse practitioner. This corrective action plan was reviewed and accepted by Licensing. On February 9, 2023, Licensing received a copy of an audit form that indicated that six persons in care received orders for ongoing tray service between January 27, 2023 and February 3, 2023.
A licensee must ensure that meals are provided by ongoing room tray service, if by ongoing room tray service, if indicated in the care plan of a person in care,
Observation: Through the investigation process, Licensing determined that a person in care was receiving meal tray service which had not been included in their care plan.
Corrective action: Ensure that if meals are provided by ongoing tray service, it is included in the care plan 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 December 18 and 22, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: by December 31, 2022, a person in care was to be assessed by the Registered Dietician (RD) and have a care plan developed for ongoing tray service, the person in care's care plan was to be reviewed with Health Care Aides (HCAs) by the Registered Nurse (RN) regarding ongoing tray service and documentation requirements and a memo was posted for staff which provided tray service education. This corrective action plan was reviewed and accepted by Licensing. On February 9, 2023, Licensing received a copy of the person in care's care plan which included tray service, a copy of a memo, dated December 20, 2022, which reviewed ongoing tray service education with staff and a letter, which stated that the person in care's care plan was reviewed with staff.