Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
23-Nov-2022
Subject
["Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)","Neglect","Recordkeeping (Includes issues such as not keeping records, insufficient records, care planning issues, health care consent, admission records.)","Nutrition and Food Service (Includes issues such as consistency, quantity, quality, feeding assistance, timing, etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must provide each person in care with nutrition supplements required by the person in care’s nutrition plan or ordered by the person in care’s medical practitioner or nurse practitioner,
Observation: Through the investigation process, Licensing determined that a person in care had not received the nutritional supplements as indicated in their care plan.
Corrective action: Ensure that a person in care is provided nutritional supplements as indicated in their 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 January 20, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: A person in care's care plan was revised to address supplement supply chain issues and was to include an alternate plan if a nutritional supplement was not available. This corrective action plan was reviewed and accepted by Licensing. On February 8, 2023, Licensing received the person in care's revised care plan which addressed supplement supply chain issues and had an alternate plan if the supplement was not available.
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 administered narcotics had not been documented.
Corrective action: Ensure that the licensee operates the facility in a manner that will promote the health, safety and dignity of persons in care. Specifically, ensure that narcotics are documented correctly. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 20, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: Narcotic count audits for each floor were to be added to the Registered Nurse (RN) daily worksheet and were to include instructions on the completion of the count and a memo was posted in the Clinician's office reviewing the CareRx policy related to Medication Administration and Documentation's section on completing narcotic counts. This corrective action plan was reviewed and accepted by Licensing. On February 8, 2023, Licensing received a copy of the RN Daily Worksheet, which included an audit of the eMAR documentation and Narcotic sign off which was completed by the end of each shift and a copy of a memo, dated January 25, 2023, addressed to nursing staff, which reviewed the Documentation Narcotic and Controlled Medication policy and reviewed requirements of documentation.
A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Through the investigation process, Licensing determined that staff had not followed the policies and procedures of the medication safety and advisory committee. Specifically, staff had not signed for or coded medications that had been administered.
Corrective action: Ensure that all staff comply with the policies and procedures of the medication safety and advisory committee. Specifically, that all staff sign for or code medications that had been administered on the Medication Administration Record (MAR). Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 20, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: the CareRX Rights of Medication Administration posters were posted on medication carts, floors and in the clinician's office, the Registered Nurse (RN) or nurse in charge worksheet was to include an audit of the eMAR completion per shift and floor, a memo was posted in the Clinician's office reviewing the CareRx policy related to Medication Administration and Documentation's section on completing narcotic counts and two staff received training on medication management and documentation . This corrective action plan was reviewed and accepted by Licensing. On February 8, 2023, Licensing received a copy of the RN Daily Worksheet, which included an audit of the eMAR documentation and Narcotic sign off which was completed by the end of each shift and a copy of a memo, dated January 25, 2023, addressed to nursing staff, which reviewed the Documentation Narcotic and Controlled Medication policy, a photograph of The 'Rights' of Medication administration that was posted for staff and letters, dated January 20, 2023, addressed to two staff, which indicated they had completed medication management training.