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- Medication Management SystemMedicationOrder
Inspectors found that a resident did not have a signed medical directive in place for a specific medication upon admission and for a period thereafter. When the resident experienced a medication incident, there was no documented medical directive to guide monitoring and treatment. The home's Medical Directives and Pre-Printed Orders policy requires that medical directives be completed and signed by a physician or nurse practitioner on move-in, but this did not occur.
- Plan Of CareCare planning
Inspectors found that a resident showing signs of health issues did not receive a specific test because the home's plan of care did not include clear directions for staff to perform that test. The home's management confirmed that the expectation for this test was not documented.
- Plan Of CareCare planning
Inspectors found that a personal support worker and a nurse did not work together to assess a resident's meal intake, which contributed to a medication incident.
- Plan Of CareCare planning
Inspectors found that a resident's plan of care did not document known triggers for the resident's responsive behaviours, even though staff were aware that certain types of care prompted these behaviours.