Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
17-Feb-2022
Subject
["Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)","Nutrition and Food Service (Includes issues such as consistency, quantity, quality, feeding assistance, timing, etc.)","Family Council"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee who provides a type of care described as Long Term Care must, if the community care facility has no resident or family council, provide an opportunity for persons in care and their parents or representatives, family members and contact persons to meet with the licensee at least twice each calendar year for the purposes of promoting the collective interests of persons in care,
Observation: Through the investigation process, Licensing identified that there had not been an opportunity, at least annually, for persons in care and their parents or representatives, family members and contact persons to establish one or more councils or similar organizations to represent the interests of the persons in care, or their parents or representatives, family members and contact persons, or both.
Corrective action: Ensure to provide an opportunity, at least annually, for persons in care and their parents or representatives, family members and contact persons to establish one or more councils or similar organizations to represent the interests of the persons in care, or their parents or representatives, family members and contact persons, or both. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On June 8, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included written confirmation that family council was reinstated and that three meetings had since occurred. The corrective action plan was reviewed and accepted by Licensing.
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 not all employees had complied with the 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 June 8 and July 13, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that by July 31, 2022 all employees who administered medication would review and sign the policies related to medication administration. The corrective action plan was reviewed and accepted by Licensing. On August 2, 2022, Licensing received written confirmation that nursing staff had completed the policy review.
A licensee must ensure that all complaints, concerns and disputes are responded to promptly.
Observation: Through the investigation process, Licensing determined that it was not ensured that all complaints, concerns and disputes are responded to promptly.
Corrective action: Ensure that all complaints, concerns and disputes are responded to promptly. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On June 8, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included that there was a new concern and complaint form and binder were created to formally respond to complaints and concerns using a single document. The corrective action plan was reviewed an accepted by Licensing. On June 8, 2022, Licensing received the concern/complaint form.
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 Licensing investigation process, Licensing identified that the community care facility was not operated in a manner that would promote the health, safety and dignity of persons in care. Specifically, in respect to one staff person demonstrating the skills necessary to carry out the duties assigned.
Corrective action: Ensure to operate the community care facility 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 June 8, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included that the staff person was no longer employed at the facility. The corrective action plan was reviewed and accepted by Licensing. On June 8, 2022, Licensing received written confirmation that the staff person was no longer employed.