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- Plan Of CareCare planning
Inspectors found that a resident's written plan of care did not include clear directions to staff about how to use a particular medication for managing symptoms. Specifically, the plan did not document that this medication should only be given after other medications had been tried first.
- Plan Of CareCare planning
Inspectors found that staff did not consistently document the care provided to residents. Reviews of point-of-care records for two residents over four- and six-month periods showed that documentation of care for various tasks was missing on multiple dates each month.
- Responsive BehavioursResponsive behaviours
Inspectors found that the home did not consistently assess, reassess, and document a resident's responsive behaviours and their response to interventions as required. Specifically, behaviour monitoring data were not collected consistently, documentation gaps prevented a complete picture of the resident's behaviours over time, and behaviour monitoring was not recorded at the point of care on day shifts before two incidents occurred.
- Administration Of DrugsMedication
Inspectors found that a medication was given to a resident on two separate occasions when there was no evidence the resident had the symptom for which the medication was prescribed to be used.