Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
16-Jul-2024
Subject
["Fall","Health and Safety","Neglect","Nutrition and Food Service (Includes issues such as consistency, quantity, quality, feeding assistance, timing, etc.)","Reporting (Includes issues such as not reporting, insufficient reporting, etc.)","Staffing (Includes issues such as suitability, insufficient levels, etc.)","Supervision"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
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 staff did not demonstrate the skills necessary to carry out the duties assigned.
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 September 24, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included that a staff received education on following the policy for mechanical lifts and using appropriate communication when addressing toileting needs. The corrective action plan was reviewed and accepted by Licensing. On October 17, 2024, Licensing confirmation that the corrective action plan had been completed.
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 person in care's care plan was not modified when there was a substantial change in the circumstances of the person in care. Specifically, related to repositioning for wound care prevention.
Corrective action: Ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of a 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 September 24, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included that on October 3, 2024, at a Clinical Practice Meeting, care plans were to be reviewed for significant changes in wounds or repositioning needs, with the Site Leader or designate ensuring care plans were in place for the next three months. The corrective action plan was reviewed and accepted by Licensing. On October 17, 2024, Licensing received confirmation that the corrective action plan had been completed.
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 licensee did not ensure to operate the community care facility in a manner that will promote the health, safety, and dignity of persons in care, specifically documentation.
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 specific to the contravention. Action/s Required by Licensing: On September 24, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: The staff received education on following the policy for mechanical lifts and using appropriate communication when addressing toileting needs. At the October 3, 2024, Clinical Practice Meeting, care plans were reviewed for significant changes in wounds or repositioning needs, with the Site Leader or designate ensuring care plans were in place for three months. On October 17, 2024, Licensing received email confirmation that the corrective action plan had been completed and implemented. This corrective action plan was reviewed and accepted by Licensing.