Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
26-Jun-2024
Subject
["Neglect","Staffing (Includes issues such as suitability, insufficient levels, etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Observation: Through the investigation process, Licensing determined that a person in care did not have sufficient access to the call bell.
Corrective action: Ensure that the community care facility is operated in a manner that will promote the health, safety and dignity of persons 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 August 14, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that staff were to conduct and document hourly checks for persons in care identified as high-risk, Nurses were to inform Health Care Aides (HCAs) of the persons in care that need to be monitored, If a call bell was not in good working order, the HCA must report it to the Licensed Practical Nurse (LPN) and the LPN then submits a maintenance request. The corrective action plan was reviewed and accepted by Licensing. On August 15, 2024, Licensing received meeting minutes, dated January 10, 2024, which addressed call bells.
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 notify the medical health officer immediately when a person in care was involved in a reportable incident.
Corrective action: Ensure that if a person in care is involved in a reportable incident, the licensee immediately notifies 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 August 14, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that staff were to notify the Wellness Manager if an incident occurred and the Wellness Manager and Licensee would submit reportable incidents to Licensing immediately. The corrective action plan was reviewed and accepted by Licensing. Following the incident, Licensing reviewed reportable incidents submitted by the Licensee, which had been submitted as required by legislation.
A licensee must operate the community care facility in a manner in the case of adult persons in care, the rights of those persons in care
Observation: Through the investigation process, Licensing determined that staff had used more than one incontinence product on a person in care at one time.
Corrective action: Ensure that the community care facility is operated in a manner that promotes the rights of persons 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 August 14, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that on January 10, 2024, a meeting was held with staff around double briefing persons in care, if an ill-fitting brief was identified, Health Care Aides (HCAs) were to report to the Licensed Practical Nurse (LPN), and two staff met with management on August 12, 2024 to review double briefing. The corrective action plan was reviewed and accepted by Licensing. On August 15, 2024, Licensing received meeting minutes that indicated double briefing was discussed with staff.
A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Observation: Through the investigation process, Licensing determined that a staff had not demonstrated the skills necessary to carry out the duties assigned. Specifically, securing a call bell out of reach of a person in care when in bed.
Corrective action: Ensure that the community care facility is operated in a manner that will promote the health, safety and dignity of persons 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 August 14, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that all Health Care Aides (HCAs) were to ensure that all persons in care have access to their call bells and the staff member met with management on August 12, 2024 around call bell access. The corrective action plan was reviewed and accepted by Licensing. On August 15, 2024, Licensing received minutes from a staff meeting which addressed call bells.