Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
14-Jan-2022
Subject
["Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)","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 ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Through the Licensing investigation process, Licensing determined that the Licensee did not ensure that staff comply with policies and procedures of the medication safety and advisory committee.
Corrective action: Ensure that all employees comply with the policies and procedures of 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 February 7, 2022, Licensee submitted a corrective action plan. The corrective action plan included assessment of competency in administering medication for all staff was completed by January 28, 2022 and education was provided to all staff related to medication policies and procedures. In addition, annually, all staff were required to undergo and complete the medication assessment to ensure competency in administering medications. All new staff were required to be orientated with medication policies and procedures in regards to medication administration and to be signed off, before administering medications. The corrective action plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection required. On May 16, 2022, Licensing received an email confirmation from the Manager stating that the corrective action plan was completed.
Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,
Observation: Through the investigation process, Licensing determined that the Licensee did not ensure each person in care was weighed at least once each month.
Corrective action: Ensure that each person in care was weighed at least once each month. 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 7, 2022, Licensee submitted a corrective action plan. This corrective action plan included monthly weights for January and February, 2022. This corrective action plan has been reviewed and accepted by Licensing. Follow Up inspection required.On May 16, 2022 Licensing received an email confirming the corrective action plan had been completed.
If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must notify a medical health officer
Observation: Through the Licensing investigation process, Licensing determined that the Licensee did not notified Licensing that the manager had resigned or was expected to be absent for at least 30 consecutive days.
Corrective action: Ensure that if the manager of a community care facility resigned, or was expected to be absent for at least 30 consecutive days, the licensee must notify a medical health officer. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing to specific to the contravention. Action/s Required by Licensing: On February 7, 2022, Licensee submitted a corrective action plan. The corrective action plan included an email confirmation which indicated that Licensing would be notified within one week in the event of a change of management moving forward. On January 20, 2022 Licensing received an notification of an application for a new manager. The corrective action plan has been reviewed and accepted by Licensing.
If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: Through the investigation process, Licensing determined that a person in care did not have a comprehensive care plan after being admitted to the community care facility for a period of more than 30 days.
Corrective action: Ensure if a person in care was admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care was made in accordance with this section within 30 days of admission. 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 7, 2022, Licensee submitted a corrective action plan. This corrective action plan included a person in care's care plan would be complete. The corrective action plan was reviewed an accepted by Licensing. Follow up inspection required. On February 21, 2022, Licensing received a person in care's care plan.