Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
15-Dec-2022
Subject
["Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care
Observation: Through the investigation process, Licensing determined that the medication record showing all administered medication given to persons in care was not kept.
Corrective action: Ensure for each person in care, a medication administration record showing all medication administered to persons in care is kept. 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 27, 2023, Registered Nurse submitted a corrective action plan to Licensing. The corrective action plan included: Medication Administration Records (MARs) for persons in care were to be reviewed on a weekly basis. Random audits of person's in care's MARs were being conducted. Weekly checks of the MAR, specifically related to documentation, were to be completed monthly after regular compliances were met. Education was provided to staff around documentation in the MAR on December 15, 2022. The corrective action plan was reviewed and accepted by Licensing. On February 27, 2023 Licensing received an email confirmation from RN, which stated that the corrective action plan was implemented.
A licensee must do all of the following:(b) 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 the health, safety and dignity of persons in care were not promoted, specifically that staff had not documented that medications had administered.
Corrective action: Ensure that the health, safety and dignity of persons in care are promoted. 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 27, 2023, Registered Nurse submitted a corrective action plan to Licensing. The corrective action plan included: Medication Administration Records (MARs) for persons in care were to be reviewed on a weekly basis. Random audits of person's in care's MARs were being conducted. Weekly checks of the MAR, specifically related to documentation, were to be completed monthly after regular compliances were met. Education was provided to staff around documentation in the MAR on December 15, 2022. The corrective action plan was reviewed and accepted by Licensing. On February 27, 2023 Licensing received an email confirmation from RN, which stated that the corrective action plan was implemented.
A licensee must keep, for each person in care, a medication administration record showing the date, amount and time at which the medication was administered.
Observation: Through the investigation process, Licensing determined staff had not kept a record showing the date, amount and time at which the medication was administered.
Corrective action: Ensure for each person in care, a medication administration record showing the date, amount and time at which the medication was administered is kept. 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 27, 2023, Registered Nurse submitted a corrective action plan to Licensing. The corrective action plan included: Medication Administration Records (MARs) for persons in care were to be reviewed on a weekly basis. Random audits of person's in care's MARs were being conducted. Weekly checks of the MAR, specifically related to documentation, were to be completed monthly after regular compliances were met. Education was provided to staff around documentation in the MAR on December 15, 2022. The corrective action plan was reviewed and accepted by Licensing. On February 27, 2023 Licensing received an email confirmation from RN, which stated that the corrective action plan was implemented.