PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: The tubroom floor has water from the shower/tub pooling after each PIC's use. The flooring in the shower area has small cracks and open dents on the wall. This was observed during the inspection of the tubroom and brought to the attention of staff.
Corrective Action(s): Please ensure that all common areas are maintained in safe and clean condition.
Date to be Corrected: October 30, 2023
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: The following was observed:
1).Medication records had missing initials for the staff administering the medications for 2 PICs for September 26, 2023.
2). A medication for PIC was found in the tubroom.
Corrective Action(s): Please ensure that all employees comply with MSAC policies
Date to be Corrected: September 30, 2023
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: The following was observed:
1). Restraint monitoring sheet was not initiated for 2/5 PICs on restraints during bedtime.
2). 1/5 PICs' on restraint use had missing agreement from PIC's family and MD in their charts. This was brought to the attention of the staff assisting with the inspection.
3). Care plan was not updated appropriately in the care plan binder for 2 PICs - this was corrected during the inspection.
4). Wound are plans were not followed appropriately for 2/4 PICs and wounds that have healed still had wound care flowsheets in the binder.
Corrective Action(s): Please ensure that all polices are implemented by staff.
Date to be Corrected: October 12, 2023
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: A used comb with no name or label was observed in the tubroom on the clean supply cart. This was brought to the attention of the staff.
Corrective Action(s): Please ensure that items intended for personal use (to ensure health and hygiene) are not available to others
Date to be Corrected: September 30, 2023
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