O:\administration\mohltc corrective action plans\plan of corrective

Ministry of Health
Ministère de la Santé
and Long-Term Care
et des Soins de longue durée
Name of Long-Term Care Facility/Nom de l’établissement de soins de longue durée Date of review/inspection/ Date de l’inspection Ministry Representative/Représentate(e) euministère From/de August 13, 2007
To/à August 16/07
Classis Hamilton Homes for the Aged o/a SHALOM MANOR,
Lisa Vink, Compliance Advisor
CHRISTOPHER
RYNBERK,
August 31, 2007
Résultats de l’inspection du ministère Plan des mesures correctives de l’établissement de SLD During the annual review the following previously
1. New bowel and bladder functioning assessments have been implemented.
identified unmet criteria have been re-issued:
2. Registered staff to be in-serviced on the above, and as follows;• skin assessments after return from hospital The assessment process shall include determining the
pain assessments when palliative and on narcotics previously
resident’s preferences, strengths and social and
personal resources, interests, health status, needs,
assessment before applying a prn restraint July 2005
extent of independent functioning type and amount of
June 2006
support required.
March 2007
This criterion has been re-issued as evidenced by:
1. Lack of bowel and bladder functioning assessments
(B1.7)
2. Two identified residents who did not have a complete
skin assessment completed within 24 hours upon return
from hospital (B1.15).
3. Lack of a current pain assessment for identified resident
who is palliative and receiving narcotics to manage pain.
4. Lack of an assessment in place for a resident who has a
Responsibility: Registered staff, DOC, CEO
Planned Date of Corrective Action: September 30, 2007
5. Lack of assessments in place (2 examples) for the needto implement a prn restraint order.
Each resident shall receive medication and treatment as
1. Registered staff were in-serviced immediately on administering the correct dosage of ordered by the physician, unless the resident refuses.
Insulin as per the sliding scale, and giving a prn medication when ordered for elevated Previously
blood pressure as per doctor’s orders.
This criterion has been re-issued as evidenced by:
2. The identified resident’s doctor’s order was corrected to ensure that the vitamin June 2006
1. Six identified diabetic residents who did not have their supplement and diuretic was ordered in accordance to the weight recording.
March 2007
capillary blood glucose levels taken as ordered in the month of August, 2007. Documentation also indicates that all six ofthese residents were also administered the incorrect dosageof insulin according to the sliding scale in August 2007. Oneresident from the period of August 4 to August 14, 2007 hasreceived the incorrect dosage of insulin 12 times.
2. An identified resident who is to have a vitaminsupplement and diuretic when the residents weight is greaterthan a specified value did not have the medicationadministered as ordered in 2 of 8 occasions in June and July2007.
3. An identified resident did not receive a prn medication asordered for a recorded elevated blood pressure in March Responsibility: Registered staff, DOC
Planned Date of Corrective Action: Immediate
1. Nursing staff to be in-serviced on their responsibilities to ensure that residents call
During this annual review the following unmet
bells are responded to within five to seven minutes to ensure that they receive care criteria has been identified:
according to their need.
2. Monitored daily be registered staff, weekly by DOC and monthly by CEO A1.11(2)
Every resident has the right to be cared for in a manner
consistent with his/her needs.
This criterion has been identified as unmet as evidenced
by:
Responsibility: Registered staff, DOC, CEO
Two identified residents who had to wait in excess of 10 Planned Date of Corrective Action: September 30, 2007
minutes on August 14,2007 to have their call bellsresponded to.
The use of a physical restraint may be continued only
1. All resident with restraints have specific orders for their restraints, indicating the type on the written order of a physician. The type of restraint
of device to be used and the application of that device.
and orders for application shall be documented and
2. Registered staff to be in-serviced on restraint orders.
reviewed at least quarterly.
3. Monitored weekly by DOC, monthly by CEO.
This criterion has been identified as unmet as evidenced
by:
1. Two identified residents who did not have orders for their
restraints in use.
2. Two identified residents who did not have specific orders
for the application of the device and one identified resident
who did not have an order indicating which device to be
Responsibility: Registered staff, DOC, CEO
Planned Date of Corrective Action: September 30, 2007
Medications, prescriptions and biologicals may be
1. Registered staff were in-serviced immediately on the following; administered to residents by Registered Nurses and
correct orders for residents returning for hospital Registered Practical Nurses according to their
correct transcribing of orders to the MAR respective standards or practice.
requirement of doctors orders for all prescription creams correct orders for Insulin as per sliding scale and for This criterion has been identified as unmet as evidenced
by:
following the sliding scale and repeating blood glucose 1. One identified example where staff did not transcribe monitoring one hour post administering of Insulin orders correctly onto a Medication Administration Record in August 2007 resulting in the resident not receiving insulin asordered from August 1 to August 13, 2007.
2. Accepting incomplete orders such as “meds as per priorto hospitalization”.
3. One example identified where a resident was receiving aprescription cream without an order from August 9 untilAugust 13, 2007.
4. Staff not seeking clarification for incomplete orders suchas: a) Lasix 40 mg T OD prn for SOB or weight gain - however the residents weight is only ordered to bemonitored weekly.
b) Humulin ge 4 times a day as per sliding scale - however the residents blood glucose levels were only beingmonitored BID three times a week.
c) Lasix 40 mg T prn for edema - with no frequency identified.
5. Not following medical directives as ordered - specificallywhen administering insulin according to the sliding scale torepeat the blood glucose monitoring one hour post Responsibility: Registered staff, DOC
administration of insulin and repeat as appropriate.
Planned Date of Corrective Action: Immediate
The homes policies and procedures shall be followed in
1. Registered staff were in-serviced on Shalom Manor’s procedures for processing the provision of care and services.
This criterion has been identified as unmet as evidenced by: Staff not processing Quarterly Medication Reviewsaccording to the procedures available in the home - at least Responsibility: Registered staff, DOC
five recent examples identified which have resulted in errors.
Planned Date of Corrective Action: Immediate

Source: http://www.shalommanor.ca/assets/uploads/pdf/PlanOfCorrectiveAction2007NURSING.pdf