Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
02-May-2024
Subject
["Neglect","Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)","Staffing (Includes issues such as suitability, insufficient levels, etc.)","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 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 staff did not demonstrate the skills and abilities necessary to carry out the duties as assigned. Specifically, a staff improperly inserted a catheter, did not follow physician orders, did not provide wound care, did not document appropriately for persons in care, and did not follow medication administration policies.
Corrective action: Ensure 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 1, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: a staff would have their practice monitored for six months, with twice-monthly meetings for three months, and monthly meetings for the following three months, a staff would review the following policies: Indwelling Urinary Catheter (insertion and care), Falls Management Program, I-Learn Falls Management Process and Policies, Administration of Medication, and Medication Administration Audit, one-to-one training would be provided to the staff by facility leadership. This corrective action plan was reviewed and accepted by Licensing. On October 18, 2024, Licensing received a copy of the practice monitoring meeting notes and education.
A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Observation: Through the investigation process, Licensing determined that the Licensee did not document appropriately in order to ensure the health, safety, and dignity of persons in care.
Corrective action: Ensure 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 1, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: all nursing staff would be provided education on documentation, including review of several policies on documentation, the policies would be reviewed during a Clinical Practice Meeting on August 2, 2024, and nurses not present at the meeting were required to sign-off that they have reviewed the meeting package documents, facility leadership would review progress notes for persons in care and shift reports daily to provide feedback to nurses as appropriate and a staff would have their practice monitored for six months, with twice-monthly meetings for three months, and monthly meetings for the following three months. This corrective action plan was reviewed and accepted by Licensing. On October 18, 2024, Licensing received confirmation that all active nursing staff had completed the education on documentation, and Licensing received copies of the staff sign-off sheet for the training on documentation, and meeting notes for the ongoing practice monitoring meetings.
A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Through the investigation process, Licensing determined that staff did not comply with the policies and procedures of the medication safety and advisory committee.
Corrective action: Ensure that all staff 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 August 1, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: all nursing staff would be provided education on documentation, including review of several policies on documentation, the policies would be reviewed during a Clinical Practice Meeting on August 2, 2024, and nurses not present at the meeting were required to sign-off that they have reviewed the meeting package documents, and medication administration audits would be completed on all active nursing staff prior to September 30, 2024. This corrective action plan was reviewed and accepted by Licensing. On October 18, 2024, Licensing received confirmation that all active nursing staff had completed the education on documentation, Licensing received copies of the the staff sign-off sheet for the training on documentation, meeting notes for the ongoing practice monitoring meetings, and copies of the medication audit forms for following policies and procedures of the medication safety and advisory committee.
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: neglect
Observation: Through the investigation process, Licensing determined that staff had subjected six persons in care to neglect.
Corrective action: Ensure that a person in care is not, while under the care or supervision of the licensee, subjected to neglect. 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 1, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: a staff would have their practice monitored for six months, with twice-monthly meetings for three months, and monthly meetings for the following three months, team huddles on prevention of abuse and neglect were presented to all care staff over May and June 2024, the Prevention of Resident Neglect and Abuse policy was added to the orientation checklist for new staff, and the policy would be reviewed at staff performance reviews for current staff, the Licensee had hired a Nurse who was responsible for the wound care program in the facility, the Nurse was consulting frontline nurses on a weekly basis in relation to any persons in care who had wounds and would create wound care plans based off those consultations. This corrective action plan was reviewed and accepted by Licensing. On August 1, 2024, Licensing received confirmation that huddles had all been completed by June 30, 2024 and on October 18, 2024, Licensing received meeting notes for the ongoing practice monitoring meetings.