Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
12-May-2023
Subject
["Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Through the investigation process, Licensing determined that an employee did not comply with the policies and procedures of the medication safety and advisory committee regarding medication administration times.
Corrective action: Ensure that all employees comply with the policies and procedures of 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 June 26, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included a meeting with the Medication Safety Advisory Committee (MSAC) to review and revise medication administration "window" times during staff shortages by July 31, 2023. The corrective action plan was reviewed and accepted by Licensing. On August 2, 2023, Licensing received the minutes from the MSAC meeting dated August 1, 2023 which included guidelines for medication administration when critical staffing shortages and a copy of an email dated August 2, 2023 regarding MSAC policy and documentation requirements when contingency plans for staff shortages were enacted that was sent to nursing staff.