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- Duty To ProtectAbuse & neglectOrder
Inspectors found that a resident was not protected from neglect. The resident had a care plan identifying refusals of food, fluids, care, and treatments, and required use of a wound healing aid. However, staff did not document or apply techniques to respond to the resident's refusals, the wound healing aid was not used properly or monitored, wound care was missed on four separate days, and the resident was not repositioned every two hours as required for seven days. The home's internal behaviour support team was not actively involved in the resident's care, and there was no evidence of reassessment or coordinated response to address the resident's ongoing refusals, resulting in unmet care needs and a decline in the resident's health status.
- Medication Management SystemMedication
Inspectors found that the home's medication management policy required staff to document telephone orders from physicians and have them signed later during a visit. However, audits showed that telephone orders for a resident were not signed by the physician as required by the policy.
- Safe Storage Of DrugsMedication
Inspectors found that controlled substances requiring refrigeration in the home's medication rooms were not stored in double-locked cupboards as required.
- Administration Of DrugsMedication
Inspectors found that a resident was given medication in crushed form, although the prescriber's instructions did not specify that the medication should be crushed.