Report AP-16-022 - City of Kingston
Transcription
Report AP-16-022 - City of Kingston
City of Kingston Information Report to Rideaucrest Home Board of Management Report Number AP-16-022 To: Chair, Rideaucrest Home Board of Management From: Lanie Hurdle, Commissioner, Community Services Resource Staff: Debra Skeaff, Administrator, Rideaucrest Home Date of Meeting: September 8, 2016 Subject: Rideaucrest Home Report for June - August 2016 Executive Summary: This report is the fourth of the bi-monthly reporting that is provided to the Rideaucrest Board of Management for 2016. The report includes statistical information on key indicators that are being reported to the Ministry of Health and Long Term Care as well as information on operations of the Home. This report contains information from June 11, 2016 through August 18, 2016. Recommendation: This report is for information purposes only. 104 Information Report to Rideaucrest Home Board of Management Report Number AP-16-022 September 8, 2016 Page 2 of 6 Authorizing Signatures: ORIGINAL SIGNED BY COMMISSIONER Lanie Hurdle, Commissioner, Community Services ORIGINAL SIGNED BY CHIEF ADMINISTRATIVE OFFICER Gerard Hunt, Chief Administrative Officer Consultation with the following Members of the Corporate Management Team: Denis Leger, Commissioner, Corporate & Emergency Services Not required Jim Keech, President and CEO, Utilities Kingston Not required Desiree Kennedy, Chief Financial Officer & City Treasurer Not required 105 Information Report to Rideaucrest Home Board of Management Report Number AP-16-022 September 8, 2016 Page 3 of 6 Options/Discussion: Operational Information and Data Rideaucrest Home has maintained an occupancy rate of 99.35% in June, 99.62% in July and 100% thus far in August. The year to date occupancy rate is 99.3%. Maintaining a high occupancy rate is important to leverage provincial funding which is based on daily envelopes per resident and the Case Mix Index (CMI). With the goal of maintaining over 98% occupancy in mind, Rideaucrest Home went live with Community Care Access Centre’s (CCAC) data integration portal on June 15, 2016. All referrals, updates and admission information for potential residents is loaded from the CCAC case workers into the web based portal for traceable, auditable and consistent information flow between the organizations. The availability of this information is key for timely admissions when bed vacancies arise. Rideaucrest Home had 10 incidents reportable to the Ministry of Health and Long Term Care (MOHLTC) during this reporting period. There are currently 389 people on the waiting list for the Home. 213 of those waiting are 4A priority who are actively seeking/requiring admission to Long Term Care. Two inspectors from the MOHLTC visited the Home June 27, 2016 through July 6, 2016 to follow up on 16 Critical Incidents and 1 Complaint. During this comprehensive inspection process, the Home received 2 Written Notifications related to one critical incident, and 1 Written Notification and an associated Voluntary Plan of Correction for a second critical incident. Extendicare statistics for average results of Assist Homes are 11 Written Notifications, 5 Voluntary Plans of Correction and 1 Order. The Local Health Integration Network (LHIN) statistics for average results are 6 Written Notifications, 2 Voluntary Plans of Correction and 1 Order. Both inspectors gave the Home great praise for the work and plans in place, they were very satisfied overall with the operations at Rideaucrest Home. Both inspectors’ Public Reports are attached as Exhibits A to E. The Home is continually preparing for Accreditation Canada to visit September 12–14, 2016. There are 4 Standards that the Accreditation Canada Surveyors review and evaluate while inspecting practices in the Home: Leadership, Long Term Care, Medication Management and Infection Control. In addition to the standards, the Surveyors will review 31 Required Organization Practices (ROPs) which are covered in 6 categories: Safety Culture, Communication, Medication Use, Worklife/Workforce Balance, Infection Control and Risk Management. There are interdisciplinary teams in place reviewing the standards and updating policies and procedures in preparation for September. Renovations are underway by Cupido Construction in preparation for the Allen-Detweiler Nursery School (ADNS) joining Rideaucrest. The Life Enrichment Coordinators, their newly hired Supervisor, Ashley Miller, and ADNS staff are working on plans for intergenerational programming to commence in October/November 2016. 106 Information Report to Rideaucrest Home Board of Management Report Number AP-16-022 September 8, 2016 Page 4 of 6 Rideaucrest is thrilled to have the terrace upgrades (wallpaper removal, patching, application of wall protector to lower half of walls and painting) in progress. The project plans are in place and a work schedule started on August 29th. Surveys are out so that residents have input on choosing colours, and a detailed plan is in place for notifying residents and families of work that will take place in their home and timelines to be expected. With guidance from the Best Practice Champion Lead and Assistant Directors of Care, the Home made a Capital purchase of 27 bolstered raised edge mattresses and 9 convertible air surface high intensity mattresses with pumps. The bolstered mattresses were mainly given to residents who had patterns of falls from bed and since their application in early July 2016 there has not been a fall from bed. Staff will continue to monitor this conclusion and if improved trends continue to be reported by the Falls Committee, staff will be considering this model for future purchases. Financials The approved 2016 operational budget for Rideaucrest Home is $5,225,323 in municipal contribution. As of the end of June 2016, Rideaucrest Home has spent 52% of its municipal contribution, which is 2% or $104K over budget. Provincial subsidy revenues are $61K greater than budget as the 2016 budget was built with an assumed CMI of 95.28 and effective April 1st, the CMI increased to 98.95. Areas over budget include nursing wages (YTD $161K) which include $67K in two unbudgeted positions of accommodated workers and incremental budget for modified workers YTD. High intensity needs claim based funding is $26K lower than budget, however, this aligns with the overtime budget being in surplus year to date. Environmental services wages are $31K overspent due to an increase in modified work routines. Lease of City Property is under budget by $14K as the Nursery School will not begin their lease until September 2016. Dietary food supplies are $21K overspent, the Food Service Supervisor is working closely with Extendicare consultants to make menu modifications and budget tracking to ensure this trend does not follow through year end. Dietary wages are $37K overspent due to three modified workers in the department. Overall accommodation revenue is higher than budget by $9K at the end of June. The MOHLTC announced Level of Care funding increases on June 30, 2016, retroactive to April 1, 2016 (Exhibit F). In terms of year over year actual funding impact, the combined CMI increase previously reported and the current 2% funding rate increase provides an additional $330K ($120K 2% rate, and $210K CMI) of revenues for the period April 1, 2016 - March 30, 2017. The Home has been in contact with the LHIN regarding the Raw Food and Other Accommodation envelope funding increases. Funding increases for these are not yet released, but is estimated to be a 1% increase; and a total of $38K higher revenues is built into the 2016 budget. 107 Information Report to Rideaucrest Home Board of Management Report Number AP-16-022 September 8, 2016 Page 5 of 6 Ministry of Health and Long Term Care Indicators Rideaucrest’s quality improvement plan is based on predetermined indicators. The quarterly Canadian Institute for Health Information (CIHI) Home specific results versus the Province for Q4 2015/16 (January – March 2016) are attached as Exhibit G to this report. Ideally, long term care homes should be performing at the same level or better than the provincial average. Rideaucrest is higher in some areas. The Home implemented a full time Best Practice Champion Lead in 2016 and this position has been focusing on bed side education in areas identified for quality improvement. Rideaucrest went live with the electronic point of care (POC) documentation in 2016. This system has great benefits for accuracy, trending and reporting, but its implementation has also been an adjustment for staff which could be part of the fluctuations seen across the reporting indicators as education continues with this new system. Stage 2-4 pressure ulcers have risen over the last reporting quarter. This is attributed to accuracy in staging. The Assistant Director of Care (previously the wound care nurse) has been educating the Best Practice Champion Lead on the accuracy of staging (i.e. sheering is not considered a pressure ulcer). Falls have increased, yet the daily physical restraints remain below the LHIN. The home invested in 27 raised bolstered edge mattresses, which to date are making a great difference in falls from bed. The physiotherapy team has marked the walls in each resident room to indicate the appropriate bed height relative to fall risk. There were two outbreaks in this CIHI reporting period and higher falls is often correlated with people being unwell. Use of antipsychotics without diagnosis of psychosis in trending downward which is attributed to a MOH funded program that the Administrator, Director of Care, Medical Director and Nurse Practitioner have attended regarding inappropriate prescribing of antipsychotic medications. Finally, worsened bladder incidents have risen and the RAI Coordinator is following trends that are documented in the POC system, monitoring declines and auditing for accuracy. The home began a trial on a new continence product system May 30, 2016. The trial has been successful and it is expected to impact results in upcoming CIHI statistics. Options/Discussion: Not applicable Existing Policy/By-Law: Not applicable Notice Provisions: Not applicable 108 Information Report to Rideaucrest Home Board of Management Report Number AP-16-022 September 8, 2016 Page 6 of 6 Accessibility Considerations: Not applicable Financial Considerations: Not applicable Contacts: Lanie Hurdle, Commissioner, Community Services 613-546-4291 extension 1231 Deb Skeaff, Administrator, Rideaucrest Home 613-530-2818 extension 4252 Other City of Kingston Staff Consulted: Laura Christopher, Supervisor, Finance & Administration, Rideaucrest Home Exhibits Attached: Exhibit A 2016_236622_0020 Inspection Report Public Exhibit B 2016_236622_0021 Inspection Report Public Copy Exhibit C 2016_444602_0022 Inspection Report Public Copy Exhibit D 2016_444602_0023 Inspection Report Public Copy Exhibit E 2016_444602_0024 Inspection Report Public Copy Exhibit F Level-of-Care Base Increase Funding 2016-17 Exhibit G Q4 CIHI Jan to March 2016 Indicators 109 Exhibit A Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée Long-Term Care Homes Division Long-Term Care Inspections Branch Division des foyers de soins de longue durée Inspection de soins de longue durée Ottawa Service Area Office 347 Preston St Suite 420 OTTAWA ON K1S 3J4 Telephone: (613) 569-5602 Facsimile: (613) 569-9670 Bureau régional de services d’Ottawa 347 rue Preston bureau 420 OTTAWA ON K1S 3J4 Téléphone: (613) 569-5602 Télécopieur: (613) 569-9670 Public Copy/Copie du public Report Date(s) / Inspection No / Date(s) du apport No de l’inspection Jul 7, 2016 Log # / Type of Inspection / Registre no Genre d’inspection 2016_236622_0020 014513-16 /008113-14 / Critical Incident 000471-14 System Licensee/Titulaire de permis THE CORPORATION OF THE CITY OF KINGSTON 216 Ontario Street KINGSTON ON K7L 2Z3 Long-Term Care Home/Foyer de soins de longue durée RIDEAUCREST HOME 175 RIDEAU STREET KINGSTON ON K7K 3H6 Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs HEATH HEFFERNAN (622) Inspection Summary/Résumé de l’inspection The purpose of this inspection was to conduct a Critical Incident System inspection. This inspection was conducted on the following date(s): June 27, 28, 29, 30 2016 and July 04, 05, 06, 2016. During the course of the inspection, the inspector(s) spoke with the Administrator, the Assistant Directors of Care, a Registered Nurse, a Personal Support Worker and the residents. The following Inspection Protocols were used during this inspection: Page 1 of/de 3 110 Exhibit A Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée Falls Prevention During the course of this inspection, Non-Compliances were not issued. 0 WN(s) 0 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s) Legend NON-COMPLIANCE / NON - RESPECT DES EXIGENCES Legendé WN – Written Notification VPC – Voluntary Plan of Correction DR – Director Referral CO – Compliance Order WAO – Work and Activity Order WN – Avis écrit VPC – Plan de redressement volontaire DR – Aiguillage au directeur CO – Ordre de conformité WAO – Ordres : travaux et activités Non-compliance with requirements under the Long-Term Care Homes Act, 2007 (LTCHA) was found. (a requirement under the LTCHA includes the requirements contained in the items listed in the definition of "requirement under this Act" in subsection 2(1) of the LTCHA). Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue durée (LFSLD) a été constaté. (une exigence de la loi comprend les exigences qui font partie des éléments énumérés dans la définition de « exigence prévue par la présente loi », au paragraphe 2(1) de la LFSLD. The following constitutes written notification Ce qui suit constitue un avis écrit de nonof non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the LTCHA. l’article 152 de la LFSLD. Page 2 of/de 3 111 Issued on this 7th Exhibit A Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée day of July, 2016 Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs Original report signed by the inspector. Page 3 of/de 3 112 Exhibit B Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée Long-Term Care Homes Division Long-Term Care Inspections Branch Division des foyers de soins de longue durée Inspection de soins de longue durée Ottawa Service Area Office 347 Preston St Suite 420 OTTAWA ON K1S 3J4 Telephone: (613) 569-5602 Facsimile: (613) 569-9670 Bureau régional de services d’Ottawa 347 rue Preston bureau 420 OTTAWA ON K1S 3J4 Téléphone: (613) 569-5602 Télécopieur: (613) 569-9670 Public Copy/Copie du public Report Date(s) / Inspection No / Date(s) du apport No de l’inspection Jul 7, 2016 Log # / Registre no 2016_236622_0021 011822-16 / 008202-16 / 004650-16 Type of Inspection / Genre d’inspection Critical Incident System Licensee/Titulaire de permis THE CORPORATION OF THE CITY OF KINGSTON 216 Ontario Street KINGSTON ON K7L 2Z3 Long-Term Care Home/Foyer de soins de longue durée RIDEAUCREST HOME 175 RIDEAU STREET KINGSTON ON K7K 3H6 Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs HEATH HEFFERNAN (622) Inspection Summary/Résumé de l’inspection Page 1 of/de 6 113 Exhibit B Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée The purpose of this inspection was to conduct a Critical Incident System inspection. This inspection was conducted on the following date(s): June 27, 28, 29, 30 2016 and July 04, 05, 06, 2016. During this inspection the following critical incident inspections were completed; M569-000018-16 - alleged staff to resident abuse/neglect M569-000013-16 - alleged staff to resident abuse/neglect M569-000006-16 - alleged staff to resident abuse/neglect During the course of the inspection, the inspector(s) spoke with the Administrator, the Assistant Director of Care, Registered Nurses, Registered Practical Nurses, Personal Support Workers and the residents. The following Inspection Protocols were used during this inspection: Dignity, Choice and Privacy Medication Personal Support Services Prevention of Abuse, Neglect and Retaliation During the course of this inspection, Non-Compliances were issued. 2 WN(s) 0 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s) Page 2 of/de 6 114 Legend Exhibit B Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée NON-COMPLIANCE / NON - RESPECT DES EXIGENCES Legendé WN – Written Notification VPC – Voluntary Plan of Correction DR – Director Referral CO – Compliance Order WAO – Work and Activity Order WN – Avis écrit VPC – Plan de redressement volontaire DR – Aiguillage au directeur CO – Ordre de conformité WAO – Ordres : travaux et activités Non-compliance with requirements under the Long-Term Care Homes Act, 2007 (LTCHA) was found. (a requirement under the LTCHA includes the requirements contained in the items listed in the definition of "requirement under this Act" in subsection 2(1) of the LTCHA). Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue durée (LFSLD) a été constaté. (une exigence de la loi comprend les exigences qui font partie des éléments énumérés dans la définition de « exigence prévue par la présente loi », au paragraphe 2(1) de la LFSLD. The following constitutes written notification Ce qui suit constitue un avis écrit de nonof non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the LTCHA. l’article 152 de la LFSLD. WN #1: The Licensee has failed to comply with LTCHA, 2007 S.O. 2007, c.8, s. 6. Plan of care Specifically failed to comply with the following: s. 6. (5) The licensee shall ensure that the resident, the resident’s substitute decision-maker, if any, and any other persons designated by the resident or substitute decision-maker are given an opportunity to participate fully in the development and implementation of the resident’s plan of care. 2007, c. 8, s. 6 (5). Findings/Faits saillants : Page 3 of/de 6 115 Exhibit B Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée 1. The licensee has failed to ensure that the resident, the SDM, if any, and the designate of the resident / SDM been provided the opportunity to participate fully in the development and implementation of the plan of care. The following finding is related to log 004650-16 On a specified date resident #002 reported to the Registered Nurse #105 that the registered practical nurse (RPN) #101 had administered him/her a medication without obtaining consent. In an interview on July 4, 2016, RPN #101 explained that on a specified date he/she informed resident #002 he/she required a medication. RPN #101 reported that resident #002 did not see his/her face and may have had difficulty hearing him/her. RPN #101 then indicated it would have been best to have ensured he/she obtained consent, however he/she did not. RPN #101 confirmed he/she administered the medication to resident #002. July 4, 2016 inspector #622 reviewed the medical directive procedure - Rideaucrest Home specific policy PHA-13-500.00 dated October 18, 2015 which indicated direction pertaining to the administration of the specified medication. On July 04, 2016, at 1130 hours, inspector #622 interviewed the Assistant Director of Care #103 who confirmed that it was his/her understanding from his/her investigation into the incident that RPN #101 had not made the care direction clear to the resident. On July 05, 2016 inspector #622 interviewed resident #002 who indicated that RPN #101 had not informed him/her, he/she was going to give the medication before administering it on the specified date. Resident #002 confirmed he/she was given the medication without knowledge and was not given a choice as to the treatment or care provided. As resident #002 was not provided clear direction regarding nor had he/she consented to the care provided, he/she was not afforded the opportunity to participate in the implementation of her plan of care. [s. 6. (5)] WN #2: The Licensee has failed to comply with O.Reg 79/10, s. 30. General requirements Page 4 of/de 6 116 Exhibit B Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée Specifically failed to comply with the following: s. 30. (2) The licensee shall ensure that any actions taken with respect to a resident under a program, including assessments, reassessments, interventions and the resident’s responses to interventions are documented. O. Reg. 79/10, s. 30 (2). Findings/Faits saillants : 1. The licensee has failed to ensure that any actions taken with respect to a resident under a program, including assessments, reassessments, interventions and the resident's responses to interventions are documented. The following finding is related to log 004650-16 Long Term Care Homes Act section 8(1) every licensee of a long-term care home shall ensure that there is, (a) an organized program of nursing services for the home to meet the assessed needs of the residents. On a specified date, resident #002 reported to the Registered Nurse (RN) #105 that Registered Practical Nurse (RPN) #101 had administered him/her a medication without obtaining consent. During the inspection, resident #002’s personal health information including; the electronic medication administration record (eMAR), the electronic treatment administration record (eTAR) and progress notes on point click care were reviewed and revealed no documentation had been completed to indicate the medication had been administered, nor the effect of the medication administered that specified date. On July 04, 2016 inspector #622 interviewed the Assistant Director of Care who indicated the administration of the medication to resident #002 was not documented. On July 04, 2016 inspector #622 interviewed Registered Practical Nurse (RPN) # 101 who confirmed he/she had not documented regarding the medication he/she gave to resident #002 or the results of the medication administered during his/her shift on the specified date. [s. 30. (2)] Page 5 of/de 6 117 Issued on this 7th Exhibit B Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée day of July, 2016 Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs Original report signed by the inspector. Page 6 of/de 6 118 Exhibit C Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée Long-Term Care Homes Division Long-Term Care Inspections Branch Division des foyers de soins de longue durée Inspection de soins de longue durée Ottawa Service Area Office 347 Preston St Suite 420 OTTAWA ON K1S 3J4 Telephone: (613) 569-5602 Facsimile: (613) 569-9670 Bureau régional de services d’Ottawa 347 rue Preston bureau 420 OTTAWA ON K1S 3J4 Téléphone: (613) 569-5602 Télécopieur: (613) 569-9670 Public Copy/Copie du public Report Date(s) / Inspection No / Date(s) du apport No de l’inspection Jul 7, 2016 Log # / Registre no 2016_444602_0022 004741-16 / 018081-16 / 024598-15 / 02459415 / 003707-16 / 004782-16 / 016295-16 / 018621-16 Type of Inspection / Genre d’inspection Critical Incident System Licensee/Titulaire de permis THE CORPORATION OF THE CITY OF KINGSTON 216 Ontario Street KINGSTON ON K7L 2Z3 Long-Term Care Home/Foyer de soins de longue durée RIDEAUCREST HOME 175 RIDEAU STREET KINGSTON ON K7K 3H6 Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs WENDY BROWN (602) Inspection Summary/Résumé de l’inspection Page 1 of/de 5 119 Exhibit C Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée The purpose of this inspection was to conduct a Critical Incident System inspection. This inspection was conducted on the following date(s): June 24, 27-30 and July 46, 2016 The Medication IP was used to inspect eight (8) medication related critical incidents as follows: Log #004741-16 - Medication error Log #018081-16 - Medication missing Log #018621-16 - Medication missing Log #016295-16 - Medication missing Log #004782-16 - Medication missing Log #003707-16 - Medication missing Log #024594-15 - Medication missing Log #024598-15 - Medication missing During the course of the inspection, the inspector(s) spoke with Residents, Personal Support Workers, (PSW)/Health Care Aides (HCA), Registered Practical Nurses (RPN), Registered Nurses (RN), the Assistant Directors of Care (ADOC), the Director of Care, and the Administrator. The inspector(s) observed various medication passes, medication cart(s) and other drug storage areas. Additionally medication administration, drug destruction practices, pharmacy provider process(es), the home’s investigation documentation and relevant policies and procedures were reviewed. The following Inspection Protocols were used during this inspection: Medication During the course of this inspection, Non-Compliances were issued. 1 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s) Page 2 of/de 5 120 Legend Exhibit C Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée NON-COMPLIANCE / NON - RESPECT DES EXIGENCES Legendé WN – Written Notification VPC – Voluntary Plan of Correction DR – Director Referral CO – Compliance Order WAO – Work and Activity Order WN – Avis écrit VPC – Plan de redressement volontaire DR – Aiguillage au directeur CO – Ordre de conformité WAO – Ordres : travaux et activités Non-compliance with requirements under the Long-Term Care Homes Act, 2007 (LTCHA) was found. (a requirement under the LTCHA includes the requirements contained in the items listed in the definition of "requirement under this Act" in subsection 2(1) of the LTCHA). Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue durée (LFSLD) a été constaté. (une exigence de la loi comprend les exigences qui font partie des éléments énumérés dans la définition de « exigence prévue par la présente loi », au paragraphe 2(1) de la LFSLD. The following constitutes written notification Ce qui suit constitue un avis écrit de nonof non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the LTCHA. l’article 152 de la LFSLD. Page 3 of/de 5 121 Exhibit C Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée WN #1: The Licensee has failed to comply with O.Reg 79/10, s. 131. Administration of drugs Specifically failed to comply with the following: s. 131. (1) Every licensee of a long-term care home shall ensure that no drug is used by or administered to a resident in the home unless the drug has been prescribed for the resident. O. Reg. 79/10, s. 131 (1). Findings/Faits saillants : 1. The licensee has failed to ensure that no drug is used by or administered to a resident in the home unless the drug has been prescribed for the resident. The following finding relates to log# 004741-16: Resident 001 was ordered a specific medication, however, on a specified date resident 001 was administered a different medication. The error was noted and the resident was assessed and sent to hospital. The resident returned to the home with no ill effects. Involved staff were provided medication administration training. Additional Required Actions: VPC - pursuant to the Long-Term Care Homes Act, 2007, S.O. 2007, c.8, s.152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that no drug is administered to a resident in the home unless the drug has been prescribed for the resident, to be implemented voluntarily. Page 4 of/de 5 122 Issued on this 7th Exhibit C Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée day of July, 2016 Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs Original report signed by the inspector. Page 5 of/de 5 123 Exhibit D Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée Long-Term Care Homes Division Long-Term Care Inspections Branch Division des foyers de soins de longue durée Inspection de soins de longue durée Ottawa Service Area Office 347 Preston St Suite 420 OTTAWA ON K1S 3J4 Telephone: (613) 569-5602 Facsimile: (613) 569-9670 Bureau régional de services d’Ottawa 347 rue Preston bureau 420 OTTAWA ON K1S 3J4 Téléphone: (613) 569-5602 Télécopieur: (613) 569-9670 Public Copy/Copie du public Report Date(s) / Inspection No / Date(s) du apport No de l’inspection Jul 7, 2016 Log # / Type of Inspection / Registre no Genre d’inspection 2016_444602_0023 013268-16 / 014802-16 Critical Incident System Licensee/Titulaire de permis THE CORPORATION OF THE CITY OF KINGSTON 216 Ontario Street KINGSTON ON K7L 2Z3 Long-Term Care Home/Foyer de soins de longue durée RIDEAUCREST HOME 175 RIDEAU STREET KINGSTON ON K7K 3H6 Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs WENDY BROWN (602) Inspection Summary/Résumé de l’inspection Page 1 of/de 3 124 Exhibit D Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée The purpose of this inspection was to conduct a Critical Incident System inspection. This inspection was conducted on the following date(s): June 24, 27-30 and July 46, 2016. Critical incident log# 013268-16 concerned alleged resident to resident sexual abuse. Critical Incident log# 014802-16 concerned alleged staff to resident abuse/neglect. During the course of the inspection, the inspector(s) spoke with residents, Personal Support Workers, (PSW) /Health Care Aides (HCA), Registered Practical Nurses (RPN), Registered Nurses (RN), the Assistant Directors of Care (ADOC), the Director of Care, and the Administrator. The inspector reviewed resident health records, interviewed staff, observed resident-resident & resident-staff interactions, as well as reviewed the Home's investigation documentation and relevant policies and procedures. Multiple observations of care and service delivery throughout the home were also completed as part of the inspection. The following Inspection Protocols were used during this inspection: Prevention of Abuse, Neglect and Retaliation Responsive Behaviours During the course of this inspection, Non-Compliances were not issued. 0 WN(s) 0 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s) Page 2 of/de 3 125 Legend Exhibit D Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée NON-COMPLIANCE / NON - RESPECT DES EXIGENCES Legendé WN – Written Notification VPC – Voluntary Plan of Correction DR – Director Referral CO – Compliance Order WAO – Work and Activity Order WN – Avis écrit VPC – Plan de redressement volontaire DR – Aiguillage au directeur CO – Ordre de conformité WAO – Ordres : travaux et activités Non-compliance with requirements under the Long-Term Care Homes Act, 2007 (LTCHA) was found. (a requirement under the LTCHA includes the requirements contained in the items listed in the definition of "requirement under this Act" in subsection 2(1) of the LTCHA). Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue durée (LFSLD) a été constaté. (une exigence de la loi comprend les exigences qui font partie des éléments énumérés dans la définition de « exigence prévue par la présente loi », au paragraphe 2(1) de la LFSLD. The following constitutes written notification Ce qui suit constitue un avis écrit de nonof non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the LTCHA. l’article 152 de la LFSLD. Issued on this 7th day of July, 2016 Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs Original report signed by the inspector. Page 3 of/de 3 126 Exhibit E Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée Long-Term Care Homes Division Long-Term Care Inspections Branch Division des foyers de soins de longue durée Inspection de soins de longue durée Ottawa Service Area Office 347 Preston St Suite 420 OTTAWA ON K1S 3J4 Telephone: (613) 569-5602 Facsimile: (613) 569-9670 Bureau régional de services d’Ottawa 347 rue Preston bureau 420 OTTAWA ON K1S 3J4 Téléphone: (613) 569-5602 Télécopieur: (613) 569-9670 Public Copy/Copie du public Report Date(s) / Inspection No / Date(s) du apport No de l’inspection Jul 7, 2016 Log # / Registre no 2016_444602_0024 012431-16 Type of Inspection / Genre d’inspection Complaint Licensee/Titulaire de permis THE CORPORATION OF THE CITY OF KINGSTON 216 Ontario Street KINGSTON ON K7L 2Z3 Long-Term Care Home/Foyer de soins de longue durée RIDEAUCREST HOME 175 RIDEAU STREET KINGSTON ON K7K 3H6 Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs WENDY BROWN (602) Inspection Summary/Résumé de l’inspection Page 1 of/de 3 127 Exhibit E Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée The purpose of this inspection was to conduct a Complaint inspection. This inspection was conducted on the following date(s): June 24, 27-30 and July 46, 2016 The complaint, identified as log#012431-16 regarded various care concerns, meal planning and food quality During the course of the inspection, the inspector(s) spoke with Residents, Personal Support Workers, (PSW)/Health Care Aides (HCA), Registered Practical Nurses (RPN), Registered Nurses (RN), the Dietary Supervisor, Life Enrichment staff, the Assistant Directors of Care (ADOC), the Director of Care, and the Administrator. The following Inspection Protocols were used during this inspection: Nutrition and Hydration Personal Support Services During the course of this inspection, Non-Compliances were not issued. 0 WN(s) 0 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s) Page 2 of/de 3 128 Legend Exhibit E Ministry of Health and Long-Term Care Ministère de la Santé et des Soins de longue durée Inspection Report under the Long-Term Care Homes Act, 2007 Rapport d’inspection sous la Loi de 2007 sur les foyers de soins de longue durée NON-COMPLIANCE / NON - RESPECT DES EXIGENCES Legendé WN – Written Notification VPC – Voluntary Plan of Correction DR – Director Referral CO – Compliance Order WAO – Work and Activity Order WN – Avis écrit VPC – Plan de redressement volontaire DR – Aiguillage au directeur CO – Ordre de conformité WAO – Ordres : travaux et activités Non-compliance with requirements under the Long-Term Care Homes Act, 2007 (LTCHA) was found. (a requirement under the LTCHA includes the requirements contained in the items listed in the definition of "requirement under this Act" in subsection 2(1) of the LTCHA). Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue durée (LFSLD) a été constaté. (une exigence de la loi comprend les exigences qui font partie des éléments énumérés dans la définition de « exigence prévue par la présente loi », au paragraphe 2(1) de la LFSLD. The following constitutes written notification Ce qui suit constitue un avis écrit de nonof non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the LTCHA. l’article 152 de la LFSLD. Issued on this 7th day of July, 2016 Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs Original report signed by the inspector. Page 3 of/de 3 129 130 131 132 Exhibit G Reporting Jan - Mar - Q4 2015 Facility Q4 2015/16 CIHI Indicator 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 Rideaucrest Daily physical restraints 9.8% 9.5% 8.9% 8.9% 8.6% Province Daily physical restraints 7.4% 7.1% 6.7% 6.3% 6.0% SE LHIN Daily physical restraints 12.6% 12.5% 12.2% 11.9% 11.3% Rideaucrest Has a stage 2-4 pressure ulcer 4.6% 4.3% 5.5% 6.1% 7.3% Province Has a stage 2-4 pressure ulcer 6.3% 6.2% 6.2% 6.1% 5.9% SE LHIN Has a stage 2-4 pressure ulcer 5.9% 5.7% 5.4% 5.4% 5.5% Rideaucrest Has fallen 20.3% 21.5% 20.6% 18.9% 19.5% Province Has fallen 14.7% 14.7% 14.8% 15.0% 15.2% SE LHIN Has fallen 15.2% 15.7% 16.0% 16.2% 16.4% Rideaucrest Taken antipsychotics without diagnosis of psychosis 27.4% 26.2% 26.0% 26.2% 24.5% Province Taken antipsychotics without diagnosis of psychosis 27.4% 26.4% 25.3% 24.2% 23.0% SE LHIN Taken antipsychotics without diagnosis of psychosis 28.1% 26.8% 25.6% 24.4% 23.3% Rideaucrest Worstened bladder continence 9.8% 11.5% 13.5% 18.2% 20.4% Province Worstened bladder continence 18.4% 18.2% 17.9% 17.6% 17.4% SE LHIN Worstened bladder continence 16.0% 16.2% 17.1% 17.3% 18.0% Rideaucrest At Least 1 Emergency Room visit Rideaucrest At Least 1 Hospital Stay 133 7 4 7 12 8 15 10 9 11 13
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