Complaint Investigation

Inspection Information

Facility Type

Residential Care - 400

Received Date

06-May-2022

Subject

["Health and Safety"]

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

Code

Category/Description

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 and the Licensee did not immediately notify a medical health officer, in the form and manner required by the medical health officer.

Corrective action: Ensure that when a person in care is involved in a reportable incident, the Licensee immediately notifies a medical health officer, in the form and 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 July 4 and September 1, 2022 the Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a review of reporting incidents at staff meetings was to occur by July 11, 2022 and nurses were to attend a Licensing in-service for Incident Reporting on September 27, 2022. The corrective action plan was reviewed and accepted by Licensing. On August 31, and September 27, 2022, Licensing received copies of staff meeting minutes and confirmation that an incident reporting in-service was completed with staff.

A licensee must do all of the following: ensure that policies are implemented by employees.

Observation: Through the investigation process, Licensing determined that the Licensee did not ensure that policies were implemented by employees.

Corrective action: Ensure that all 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: On August 31 and September 1, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a review of policies regarding two person care was to occur at staff meetings, reminders to request support of other staff, and spot checks for compliance with two person care policy was to be completed by July 4, 2022. This corrective action plan was reviewed and accepted by Licensing. On August 31, 2022, Licensing received copies of the staff meeting minutes, and confirmation that spot checks were occurring.

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 the community care facility was not operated in a manner that promoted the health, safety and dignity of persons in care. Specifically, that staff did not demonstrate the skills necessary to carry out the duties assigned.

Corrective action: Ensure that the community care facility is operated in a manner that promotes the health, safety and dignity of person in care. Specifically, that all staff have the character and skills necessary to carry out the duties assigned. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On July 4 and September 1, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a review at staff meetings of policies related to two person care and reminders to request support when short staffed for bathing, random spot checks were conducted to ensure two person care was not done alone, and a memo was posted to advise staff to email the Director of Care (DOC) for the bath workload team by July 2022. The corrective action plan was reviewed and accepted by Licensing. On August 31, 2022, Licensing received copies of the staff meeting minutes and posted memo, and confirmation that spot checks were occurring.

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 the Licensee did not ensure that a person in care was not, while under the care or supervision of the Licensee, subjected to neglect.

Corrective action: Ensure that a person in care is not, while under the care and 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 July 4 and September 1, 2022 Licensee submitted a corrective action plan to Licensing. The corrective action plan included: review at staff meetings of policies related to two person care, reminders to request support when short staffed for bathing, random spot checks to ensure two person care was not done alone, and a memo was posted to advise staff to email the Director of Care (DOC) for the bath workload team by July 2022. The corrective action plan was reviewed and accepted by Licensing. On August 31, 2022, Licensing received copies of the staff meeting minutes and posted memo, and confirmation that spot checks were occurring.