Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
27-Dec-2023
Subject
["Neglect","Dispute Resolution","Physical Plant/Equipment (Includes issues such as cleanliness, state of repair, insufficient quantity of supplies, smoking/vaping 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 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 persons in care were subjected 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 February 27, 2024 and March 14, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: The staff were re-educated and required to complete courses on Bill of Rights and abuse and neglect. The corrective action plan was reviewed and accepted by Licensing. On May 8, 2024 Licensing received confirmation that re-education related to completion of courses noted in the corrective action plan was ongoing.
To be corrected by: 08-Jul-2024
A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to assist persons in care with activities of daily living, including eating, mobility, dressing, grooming, bathing and personal hygiene, in a manner consistent with the health, safety and dignity of persons in care.
Observation: Through the investigation process, Licensing determined that the licensee did not have a sufficient number of employees on duty to assist persons in care with personal hygiene.
Corrective action: Ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to assist persons in care with activities of daily living, including eating, mobility, dressing, grooming, bathing and personal hygiene, in a manner consistent with 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 February 27, 2024 and March 14, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: The facility continued hiring efforts, utilized a staffing agency and implemented a hiring plan to attract staff. This corrective action plan was reviewed and accepted by Licensing. On May 8, 2024 Licensing received evidence that the number of overall staff number had increased with supporting agency staff use decreased and hiring was ongoing.
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 the licensee did not immediately notify a medical health officer, in the form and in the manner required by the medical health officer, about a reportable incident.
Corrective action: Ensure that 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. 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 27, 2024 and March 14, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: The staff were re-educated and required to complete a course on incident reporting. This corrective action plan was reviewed and accepted by Licensing. On May 8, 2024 Licensing received confirmation that re-education related to completion of courses noted in the corrective action plan was ongoing.
To be corrected by: 08-Jul-2024
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 that the facility did not complete accurate documentation of person in care's care needs.
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 February 27, 2024 and March 14, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: The staff were re-educated and required to complete a courses on proper documentation. This corrective action plan was reviewed and accepted by Licensing. On May 8, 2024 Licensing received confirmation that re-education related to completion of courses noted in the corrective action plan was ongoing.
To be corrected by: 08-Jul-2024
A licensee must ensure that all furniture and equipment for use by persons in care meet the needs of the persons in care,
Observation: Through the investigation process, Licensing determined that the facility did not have the proper equipment for use by persons in care to meet the needs of the persons in care.
Corrective action: Ensure that all furniture and equipment for use by a persons in care meet the needs of the 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 February 27, 2024 and March 14, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: The family of the person in care had a care conference on March 18, 2024 and discussed options for trials and purchase of specialty equipment, the facility obtained the bariatric equipment required to meet the needs of the person in care, and staff were to use the pre-admission care conference assessment and admission checklist within seven days of all new admissions. This corrective action plan was reviewed and accepted by Licensing. On May 8, 2024 Licensing received confirmation that the new equipment had been procured and was waiting arrival, and the preadmission care conference assessment and admission checklist review was completed and done at move in.
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 a person in care did not have appropriate bedding to ensure a healthy environment.
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 February 27, 2024 and March 14, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included that extra linen supplies were obtained to meet the person in care's needs. This corrective action plan was reviewed and accepted by Licensing. On May 8, 2024 Licensing received confirmation that the Occupational Therapist requested the linens were not to be used due to the maxi-slider use.
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 a person in cares brief had been marked with marker.
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 February 27, 2024 and March 14, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: The staff were re-educated on risk associated with marking continence products with a marker. The corrective action plan was reviewed and accepted by Licensing. On May 8, 2024 Licensing received confirmation that education related to completion of courses noted in the corrective action plan was ongoing.
To be corrected by: 08-Jul-2024