Complaint Investigation

Inspection Information

Facility Type

Residential Care - 400

Received Date

19-Apr-2022

Subject

["Neglect","Health and Safety","Physical Plant/Equipment (Includes issues such as cleanliness, state of repair, insufficient quantity of supplies, smoking/vaping etc.)"]

Contraventions: A summary of the new contraventions found during the inspections are listed below.

Code

Category/Description

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 staff had not documented person in care's baths appropriately.

Corrective action: Ensure the community care facility operates in a manner that promotes the health, safety and dignity of persons in care. Specifically, that documentation is completed. 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 19 and June 2, 2022, Licensee submitted a corrective action plan to Licensing specific to the contravention. The corrective action plan included that all staff were to be educated regarding proper documentation of baths on Point Click Care (PCC) by June 3, 2022, a notification regarding documentation processes and expectations was to be posted in PCC communication by June 3, 2022 and leadership staff were to complete bathing documentation audits on one floor per week for the next four weeks. This corrective plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection Required. On August 25 and 25, 2022, Licensing received a memo on paper and PCC, dated August 24, 2022, addressed to staff who use Point of Care (POC) and the expectations related to documentation, POC Coding education, dated July 12, 2022 which had been signed by multiple Health Care Aides (HCAs), a weekly bathing documentation audit, dated May 2022, which indicated that baths had been appropriately documented by staff and POC bathing documentation education, dated between June 17 and 24, 2022, which had been signed by multiple staff.

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 medical health officer had not been informed when a person in care was involved in a reportable incident.

Corrective action: Ensure that if a person in care was involved in a reportable incident, that the medical health officer is 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 19 and June 2, 2022, Licensee submitted a corrective action plan to Licensing specific to the contravention. The corrective action plan included that all staff were to be educated regarding reportable incidents and the proper process for reporting to the physician, staff were provided with reporting forms on each nursing unit with directions for use and the process and procedure for staff to follow to report an incident was posted in the nursing stations on all units by June 3, 2022. This corrective plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection Required. On August 25 and 25, 2022, Licensing received Reportable Incident education, dated between June 17 and 24, 2022, which had been signed by multiple staff members, a list of reportable incidents that was posted at each nursing station and an incident report which had been highlighted to show areas that required completion for staff guidance.

Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify the medical practitioner or nurse practitioner responsible for the care of the person in care,

Observation: Through the investigation process, Licensing determined that the facility had not notified the physician when a person in care was involved in a reportable incident.

Corrective action: Ensure that if a person in care was involved in a reportable incident, that the medical or nurse practitioner who was responsible for the care of the person in care was notified. 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 19 and June 2, 2022, Licensee submitted a corrective action plan to Licensing specific to the contravention. The corrective action plan included that all staff were to be educated regarding reportable incidents and the proper process for reporting to the physician, staff were provided with reporting forms on each nursing unit with directions for use and the process and procedure for staff to follow to report an incident was posted in the nursing stations on all units by June 3, 2022. This corrective plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection Required. On August 25 and 25, 2022, Licensing received Reportable Incident education, dated between June 17 and 24, 2022, which had been signed by multiple staff members, a list of reportable incidents that was posted at each nursing station and an incident report which had been highlighted to show areas that required completion for staff guidance.

Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify the medical practitioner or nurse practitioner responsible for the care of the person in care,

Observation: Through the investigation process, Licensing determined that the facility had not notified the physician when a person in care was involved in a reportable incident.

Corrective action: Ensure that if a person in care was involved in a reportable incident, that the medical or nurse practitioner who was responsible for the care of the person in care was notified. 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 19 and June 2, 2022, Licensee submitted a corrective action plan to Licensing specific to the contravention. The corrective action plan included that all staff were to be educated regarding reportable incidents and the proper process for reporting to the physician, staff were provided with reporting forms on each nursing unit with directions for use and the process and procedure for staff to follow to report an incident was posted in the nursing stations on all units by June 3, 2022. This corrective plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection Required. On August 25 and 25, 2022, Licensing received Reportable Incident education, dated between June 17 and 24, 2022, which had been signed by multiple staff members, a list of reportable incidents that was posted at each nursing station and an incident report which had been highlighted to show areas that required completion for staff guidance.

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 staff had not documented person in care's baths appropriately.

Corrective action: Ensure the community care facility operates in a manner that promotes the health, safety and dignity of persons in care. Specifically, that documentation is completed. 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 19 and June 2, 2022, Licensee submitted a corrective action plan to Licensing specific to the contravention. The corrective action plan included that all staff were to be educated regarding proper documentation of baths on Point Click Care (PCC) by June 3, 2022, a notification regarding documentation processes and expectations was to be posted in PCC communication by June 3, 2022 and leadership staff were to complete bathing documentation audits on one floor per week for the next four weeks. This corrective plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection Required. On August 25 and 25, 2022, Licensing received a memo on paper and PCC, dated August 24, 2022, addressed to staff who use Point of Care (POC) and the expectations related to documentation, POC Coding education, dated July 12, 2022 which had been signed by multiple Health Care Aides (HCAs), a weekly bathing documentation audit, dated May 2022, which indicated that baths had been appropriately documented by staff and POC bathing documentation education, dated between June 17 and 24, 2022, which had been signed by multiple staff.

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 medical health officer had not been informed when a person in care was involved in a reportable incident.

Corrective action: Ensure that if a person in care was involved in a reportable incident, that the medical health officer is 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 19 and June 2, 2022, Licensee submitted a corrective action plan to Licensing specific to the contravention. The corrective action plan included that all staff were to be educated regarding reportable incidents and the proper process for reporting to the physician, staff were provided with reporting forms on each nursing unit with directions for use and the process and procedure for staff to follow to report an incident was posted in the nursing stations on all units by June 3, 2022. This corrective plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection Required. On August 25 and 25, 2022, Licensing received Reportable Incident education, dated between June 17 and 24, 2022, which had been signed by multiple staff members, a list of reportable incidents that was posted at each nursing station and an incident report which had been highlighted to show areas that required completion for staff guidance.