Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
02-Sep-2022
Subject
["Physical Plant/Equipment (Includes issues such as cleanliness, state of repair, insufficient quantity of supplies, smoking/vaping etc.)","Policies (Includes issues such as not following, insufficient information or policy missing)","Staffing (Includes issues such as suitability, insufficient levels, etc.)","Health and Safety","Neglect"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
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 a person in care's care plan had not been revised to include verbal aggression or refusal of 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 October 21, 2022, Licensee submitted a corrective action plan to Licensing specific to the contravention. The corrective action plan included that by October 25, 2022, the Care Plan Initiation and Review- LTC Policy was to be posted on all units and by the staff sign in clock, by October 31, 2022, a person in care’s care plan was revised to include verbal aggression and refusal of care, staff were made aware of these changed by using the Licensed Practical Nurse (LPN) worksheet which was to be reviewed at the beginning of the shift for the following four days and by November 11, 2022, all regular LPNs and Registered Nurses (RNs) were to review the Care Plan Initiation and Review- LTC Policy and sign letters of acknowledgment. This corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection Required. On December 6 and 7, 2022, Licensing received a copy of the posted memo which reviewed care plans and staff roles in the care planning process, a copy of a person in care's care plan which was revised to include verbal aggression and refusal of care, the LPN daily worksheet, dated November 13, 13, 15 and 16, 2022, which indicated the person in care's care plan had been reviewed with staff and acknowledgment letters, signed by several staff, dated October 25, 2022, which reviewed the Care Plan Initial and Review Policy.