Complaint Investigation

Inspection Information

Facility Type

Residential Care - 400

Received Date

17-Dec-2021

Subject

["Staffing (Includes issues such as suitability, insufficient levels, etc.)","Health and Safety"]

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 the date, amount and time at which the medication was administered.

Observation: Through the investigation process, Licensing observed that the licensee did not keep for each person in care, a medication administration record showing the date, amount and time at which the medication was administered.

Corrective action: Ensure that that the licensee keep for each person in care, a medication administration record showing the date, amount and time at which the medication was administered. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On March 29, 2022, the Licensee submitted a corrective action plan to licensing which included all staff participating in a medication training session. This corrective action plan was reviewed and accepted by Licensing. On May 27, 2022, the Licensee confirmed the staff had completed the program.

A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.

Observation: Through the investigation process, Licensing observed that the licensee did not ensure that the care and supervision of a person in care was consistent with the terms and conditions of the person in care's care plan.

Corrective action: Ensure that the care and supervision of a person in care was consistent with the terms and conditions of the person in care's care plan. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On March 29, 2022, the licensee submitted a corrective action plan to licensing which included all staff participating in a training including in house competency training. This corrective action plan was reviewed and accepted by Licensing. On May 29, 2022, the Licensee confirmed the staff had completed the program.

A licensee must ensure that a person in care is not, while under the care or supervision of the licensee subjected to any of the following types of abuse or neglect, as described in section 1 of Schedule D: emotional abuse

Observation: Through the investigation process, Licensing observed that the Licensee had not ensured that a person in care was not while under the care or supervision of the licensee subject to emotional abuse.

Corrective action: Ensure that a person in care is not, while under the care or supervision of the licensee, subjected to emotional abuse. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: Licensee to submit a corrective action plan to licensing specific to the contravention. On March 29, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included staff training on sensitivity and the Bill of Rights. This corrective action plan was reviewed and accepted by Licensing. On May 27, 2022, the manager confirmed by telephone that the training had been completed.

A licensee must ensure that employees who store, handle or administer medication to persons in care have successfully completed any training programs established by the medication safety and advisory committee

Observation: Through the investigation process, Licensing observed that the Licensee did not ensure that employees who store, handle or administer medications to persons in care have successfully completed any training programs established by the medication safety and advisory committee. On March 29, 2022, the Licensee submitted a corrective action plan to Licensing which included all staff participating in a medication training session. On May 27, 2022, the Licensee confirmed the staff had completed the program.

Corrective action: Ensure all employees who store, handle or administer medications to persons in care have successfully completed any training programs established by the medication safety and advisory committee. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On March 29, 2022, the Manager submitted a corrective action plan which included staff to be trained on programs established by medical safety and advisory committee. This corrective action plan was reviewed and accepted by Licensing. On May 27, 2022, Licensing spoke with the Manager who confirmed the corrective action plan had been completed.

A licensee must ensure that a pharmacist records all medications on the person in care’s medication administration record.

Observation: Through the Licensing investigation process, Licensing observed that the pharmacist had not recorded all medications on the person in care's medication administration record.

Corrective action: Ensure the pharmacist records all medications on the person in care's medication administration record. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On March 29, 2022, the Licensee submitted a corrective action plan to Licensing which included training for staff on medication policies and procedures. This corrective action plan was reviewed and accepted by Licensing. On May 27, 2022 the Manager confirmed by telephone that the training had been completed.

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 the facility was not operated in a manner that would promote the health and safety of persons in care.

Corrective action: Ensure the facility was operated in a manner that will promote the heath and safety 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 March 29, 2022, the Manager submitted a corrective action plan which included the Manager being on site for 20 hours per week. This corrective action plan was reviewed and accepted by Licensing. On May 27, 2022 Licensing spoke with manager who confirmed a fulltime manager was being hired for the site and the manager will be on site 20 plus hours per week.