Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
23-Mar-2023
Subject
["Access to Health Services (Includes access to physician, dentist, OT, PT, etc.)","Neglect","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 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 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 April 24, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: the Manager had secured a new foot care nurse on April 4, 2023, the Manager would contact the the Licensee every six weeks to report that foot care was completed until November 2023, the Licensee was to review agency policies with the Manager regarding neglect and documentation standards, and starting May 1, 2023, the representative for the person in care would provide monthly updates regarding ongoing health needs and to pass any concerns to the Manager. The corrective action plan was reviewed and accepted by Licensing. On May 31, 2023, Licensing was notified that the person in care had their first appointment with the new foot care nurse, the Manager and Licensee met on May 2, 2023 and reviewed the policies on abuse and neglect as well as education was provided regarding neglect, and this information was also reviewed with staff in a team meeting held on May 12, 2023. Licensing to review and monitor this corrective action plan.
A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Observation: Through the investigation process, Licensing determined that the Licensee did not ensure that the care plan for a person in care was reviewed and modified with a substantial change in the circumstances of the person in care.
Corrective action: Ensure that each care plan is reviewed and if necessary, modified if there is a substantial change in the circumstances 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 April 24, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that the Manager would review agency policies regarding documentation standards and bring forward their learning at the May 2023 team meeting, the Manager and Licensee would review the current care plan for a person in care and highlight all areas that required updating by May 31, 2023 and the Manager would review the updated care plan with staff at the team meeting in June 2023. This corrective action plan was reviewed and accepted by Licensing. On May 31, 2023, Licensing was made aware that the updated care plan for he person in care was sent to family for review and input on May 12, 2023, and the document was finalized on May 29, 2023.