Complaint Investigation

Inspection Information

Facility Type

Residential Care - 400

Received Date

15-Feb-2024

Subject

["Aggression between Persons in Care"]

Contraventions: A summary of the new contraventions found during the inspections are listed below.

Code

Category/Description

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 the care and supervision of a person in care was not consistent with the terms and conditions of the person in care's care plan. Specifically, related to staff not administering medication according to the 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: on April 9, 2024, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included: the nursing staff involved in this incident reviewed the medications and care plan for the person in care affected with the care manager on February 16, 2024. The corrective action plan was reviewed and accepted by Licensing. On April 9, 2024, Licensing received confirmation that the employee involved had completed the review of medication care plans.

Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer

Observation: Through the investigation process, Licensing determined that a person in care was involved in a reportable incident that was not reported immediately.

Corrective action: Ensure that if a person in care is involved in a reportable incident, that the licensee immediately notifies a medical health officer, in the form and in the manner required by the medical health officer. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On April 9, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: All Registered Nurses responsible for reporting, would review reportable incidents and place the review in the Care Plan and Resident's Day as soon as possible and alert staff to the changes. The corrective action plan was reviewed and accepted by Licensing. On April 18, 2024, Licensing received confirmation that all reportable incidents had been reviewed by nurses on April 8, 2024.

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 determined that the Licensee did not ensure that all employees who store, handle or administer medication to persons in care had completed all training programs established by the medication safety and advisory committee.

Corrective action: 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. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: on April 9, 2024, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included: nursing staff involved in this incident reviewed the medications and care plan for the person in care affected with the care manager on February 16, 2024, an employee without required medication administration training would not administer medications and would complete medication administration orientation checklist prior to resuming medication administration. The corrective action plan was reviewed and accepted by Licensing. On April 18, 2024, Licensing received a copy of the involved employee's completed medication administration checklist dated April 3, 2024.

A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care

Observation: Through the investigation process, Licensing determined that a care plan was not reviewed and modified when there was a substantial change in the circumstances of the person in care.

Corrective action: Ensure that for each person in care the care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person 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 April 9, 2024, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included: The Care Plan and Resident's Day for a person in care was updated on April 9, 2024. The corrective action plan was reviewed and accepted by Licensing. On April 9, 2024, Licensing received a copy of the updated care plan, which included physical aggression and appropriate interventions.