Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
24-Nov-2023
Subject
["Recordkeeping (Includes issues such as not keeping records, insufficient records, care planning issues, health care consent, admission records.)","Neglect"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must do all of the following: ensure that policies are implemented by employees.
Observation: Through the investigation process, Licensing determined that a staff had not implemented the policy related to wound care audits.
Corrective action: Ensure that policies are implemented by employees. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: Between January 22 and 25, 2024 Licensee submitted a corrective action plan to Licensing. The corrective action plan included the Registered Nurses (RNs) and Director of Care (DOC) and Assistant Director of Care (ADOC) would conduct weekly wound care audits as per policy and a months worth of audits would be provided to Licensing by February 23, 2024. The corrective action plan was reviewed and accepted by licensing. On February 21, 2024 Licensing received a copy of the wound care audits.
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 determined that a staff had not followed a person in care's care plan.
Corrective action: 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. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: Between January 22 and 25, 2024 Licensee submitted a corrective action plan to Licensing. The corrective action plan included a staff member was met with to discuss expectations around adhering to care plans and was required to read and sign the wound management policy and process by February 9, 2024. In addition, a meeting was held on November 23, 2023 with all nursing staff to discuss wounds and adhering to person in care's care plans. The corrective action plan was reviewed and accepted by Licensing. On January 25, 2024 Licensing received a copy of the signed meeting minutes and on February 9, 2024 Licensing received a copy of the signed policies by the staff member.