Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
09-Jan-2023
Subject
["Health and Safety","Physical Abuse","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 care plan must include all of the following: a plan to address behavioural intervention, if applicable
Observation: Through the investigation process, Licensing determined that a care plan for a person in care did not address behavioural intervention when required.
Corrective action: Ensure that a care plan includes a plan to address behavioural intervention, if applicable. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On February 12 and 24, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: a process was initiated where the wellness team conducted a review and ongoing assessment to address persons in care who's care needs had changed, update the care plans every 30 days and six months after admission and with a change in condition, and that all care plans updated alerted the staff team and the staff signed off that they had reviewed the updated care plan. This corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan.
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 licensee did not immediately notify a medical health officer, in the form and in the manner required by the medical health officer, about a reportable incident.
Corrective action: Ensure that 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. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On February 10 and 24, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: the Director of Wellness and Lead Wellness Nurse attended the Licensing Manager Orientation Session on January 26, 2023 and provided education on reportable incidents to the nursing team. This corrective action plan was reviewed and accepted by Licensing. On February 24, 2023 Licensing received a copy of the training with staff signatures.
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 care plans were not reviewed and, if necessary, modified if there is 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 specific to the contravention. Action/s Required by Licensing: On February 12 and 24, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: a process was initiated where the wellness team conducted a review and ongoing assessment to address persons in care who's care needs had changed, update the care plans every 30 days and six months after admission and with a change in condition, and that all care plans updated alerted the staff team and the staff signed off that they had reviewed the updated care plan. This corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan.