Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
17-Jan-2022
Subject
["Restraints","Physical Abuse","Staffing (Includes issues such as suitability, insufficient levels, etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
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 the care plans for persons in care had not been updated to include resistance to care behaviour and appropriate interventions.
Corrective action: Ensure that care plans for persons in care are 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 March 31, 2022, Licensee submitted a corrective action plan which included a review of all care plans and modifications to care plans, as needed, to ensure appropriate strategies were implemented in regard to resistive behaviour, to be completed by April 6, 2022. The corrective action plan was reviewed and accepted by Licensing. On May 12, 2022, Licensing received an email from the Manager confirming that all care plans for persons in care had been reviewed and revised for behaviour strategies, as needed.
Subject to subsection (2), a licensee may restrain a person in care if the restraint is necessary to protect the person in care or others from imminent serious physical harm
Observation: Through the investigation process, Licensing determined that staff used restraint when it was not necessary to protect the persons in care and others from imminent serious physical harm.
Corrective action: Ensure that a restraint is only used to protect the person in care or others from imminent serious harm. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On March 31, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included identifying persons in care with resistive behaviour and to update care plans by April 6, 2022, to ensure appropriate strategies were implemented and restraints not utilized, except in the event of an emergency. Additionally, to draft and communicate to nurses the emergency restraint process by April 18, 2022. The corrective action plan was reviewed and accepted by Licensing. On May 13, 2022, Licensing received an email confirming the completion of all care plan reviews and modifications, staff sign off that revised care plans and emergency restraint had been reviewed and received a copy of an updated "Least Restraint Policy: Emergency Use of Restraints".
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 had not ensured that the policies were implemented by employees.
Corrective action: Ensure that 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 March 31, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included updating "Least Restraint Policy: Emergency Use of Restraint", to include process and documentation for nursing staff and sign off of all staff acknowledging review of emergency restraint policies by April 18, 2022. The corrective action plan was reviewed and accepted by Licensing. On May 12, 2022, Licensing received the updated "Least Restraint Policy" with additional process information for staff and a sign off sheet for staff acknowledging review of policy.
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 operate the community care facility in a manner that promoted the health, safety and dignity of persons in care. Specifically, that staff had not used appropriate skills to communicate with a person in care.
Corrective action: Ensure that 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 March 31, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included that a staff was required to complete "Personhood - Modules 1 and 2" by April 8, 2022 and submit certificate of completion. Additionally, all staff received posted communication on March 31, 2022, regarding appropriate communication with persons in care. The corrective action plan was reviewed and accepted by Licensing. On May 18, 2022, Licensing received a copy of staff completion certificate for "Personhood in Practice: Part 1 and 2" and signed staff acknowledgement of Respectful Communication expectations.
A licensee must do all of the following: operate the community care facility in a manner that will promote in the case of adult persons in care, the rights of those persons in care;
Observation: Through the investigation process, Licensing determined that the Licensee did not operate the community care facility in a manner that will promote, in the case of adult persons in care, the rights of those persons in care.
Corrective action: Ensure that the facility is operated in a manner that will promote, in the case of adult persons in care, the rights of those 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 March 31, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included staff sign off acknowledging understanding of Bill of Rights, posted in communication books, by April 15, 2022. Additionally, Bill of Rights online course would be added to staff orientation checklist. This corrective action plan was reviewed and accepted by Licensing. On May 12, 2022, Licensing received sign off sheets for staff acknowledging understanding of Bill of Rights and a copy of the orientation agenda which included Bill of Rights completion on SURGE online learning.