Cedarwood Lodge of 860 Great Northern Road is under the gun again after inspectors found about a dozen cases on non-compliance by the Ministry of Health and Long-Term Care under the Long-Term Care Homes Act of 2007.
These include: one critical incident submitted to the Director related to an allegation of staff to resident neglect; two critical incidents submitted to the Director related to resident to resident abuse, one critical incident submitted to the Director related to resident falls, one critical incident submitted to the Director related to improper care of a resident; and, four complaints submitted to the Director related to the care of residents.
This inspection was conducted on the following date(s): September 18-22, and 25-29, 2017. The report was not made public until just recently.
The purpose of this inspection was to conduct a Resident Quality Inspection.
During the course of the inspection, the inspector(s) spoke with the Administrator, Director of Care (DOC), Life Enrichment Manager, Dietary Services Manager, Registered Dietitian (RD), Physiotherapist, Resident Assessment Instrument (RAI) Coordinator, Registered Nurses (RNs), Registered Practical Nurses (RPNs), Personal Support Workers (PSWs), Food Service Worker (FSW), family members and residents.
The inspector(s) also conducted a daily tour of resident care areas, observed the provision of care and services to residents, observed staff to resident interactions, reviewed relevant health care records, staff personnel files and reviewed numerous licensee policies, procedures, and programs.
Written Notification #1: The licensee has failed to ensure that there was a written plan of care for each resident that set out clear direction to staff and others who provided the direct care to the resident. The licensee has failed to ensure that the resident, the resident’s substitute decision-maker, if any, and any other person designated by the resident or substitute decision-maker was given the opportunity to participate fully in the development of the resident’s plan of care. The licensee has failed to ensure that the care set out in the plan of care was provided to the resident as specified in the plan. A Critical Incident (CI) report was submitted to the Director on a specific date, for an incident of abuse that occurred a number of days prior. During a health care record review, it was identified that resident #009 had experienced a number of falls over a 19-day period.
A compliance order was issued.
Written Notification #2: The licensee has failed to ensure that a person who had reasonable grounds to suspect that any of the following had occurred or may occur shall immediately report the suspicion and the information upon which it was based to the Director: abuse of a resident by anyone or neglect of a resident by the licensee or staff that resulted in harm or a risk of harm to the resident or improper or incompetent treatment or care of a resident that resulted in harm or a risk of harm to the resident. A Critical Incident (CI) report was submitted to the Director on a particular date, for an incident that had occurred a number of days prior. The CI report submitted under Improper/ Incompetent treatment of a resident alleged that a staff member improperly transferred residents #010 and #011. Inspector #542 reviewed a Critical Incident (CI) report that was submitted to the Director on a particular date, for an alleged incident of abuse that had occurred on a particular date. The CI report indicated that resident #016 performed an action towards another resident.
A second compliance order was issued.
Written Notification #3: The licensee has failed to ensure that residents were protected from abuse by anyone and that residents were not neglected by the licensee or staff.
A third compliance order was issued.
Written Notification #4: The licensee has failed to ensure that when a resident had fallen, the resident was assessed and that where the condition or circumstance of the resident required, a post-fall assessment was conducted using a clinically appropriate assessment instrument that was specifically designed for falls.
A fourth compliance order was issued.
Written Notification #5: The licensee has failed to ensure that the following requirement was met with respect to the restraining of a resident by a physical device under section 31 or section 36 of the Act: staff apply the physical device in accordance the manufacturer’s instruction. On September 21, 2017, Inspector #542 completed a health care record review for resident #015. The care plan included documentation to indicate that the resident was to have a specific device in place when using their mobility aid. During an interview with RN #112 on September 28, 2017, they stated that registered staff were to sign off on the Restraint Monitoring Record every eight hours. RN #112 stated that the purpose of them signing was to ensure that the PSW’s documented their hourly checks. No hourly signatures were in place on four specific dates in eight hour periods. If signatures from the PSW’s were missing, they were responsible to notify the PSW’s to complete their documentation on the sheet. RN #112 further stated that PSWs should have identified and documented what they had done with the device such as applying, monitoring and releasing.
A fifth compliance order was issued.
Written Notification #6: The licensee has failed to ensure that the policy promoting zero tolerance of abuse and neglect was complied with.The statement identified that on a particular date, staff found resident #012 sitting in a unclean bed. The statement identified that resident #012 was upset stating that they required assistance and no one would help them.
Furthermore, the letter identified that RN #108 commented to the staff that resident #012 was yelling the “entire time” and when approached to ask why the resident was left in that condition RN #108 stated “what did you want me to do about it?”.
Inspector #679 reviewed a document dated on a particular date, which indicated that RN #108 was terminated from the home on specific grounds.
In an interview with the DOC on September 26, 2017, they indicated that the neglect was substantiated and that RN #108 was terminated from the home
The other eight written notifications mandated a voluntary plan of correction.