Murray House (P.D.S.C.L.)
110 Murray Dr Penticton BC V2A 7E4 · Residential Care - Licensing
8 inspections
- Routine Inspection
1 infraction
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): Chart's reviewed that has restraint agreement's however no process in place to document restraint monitoring. Failure to have restraint monitoring documentation in place can result in unsafe practices and possible injury posing serious risk to persons in care. Please submit a corrective action plan by January 14, 2025, advising how all current and future restraint monitoring documentation will be completed in an efficient and timely manner.
- R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
- R4.3 - Is documentation concerning restraints adequate?
- Routine Inspection
5 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): Licensing Officer reviewed multiple restraint agreements which did not contain the proper consents.
- R2.2B - Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73( 2 ); 75( 2 )(a)(i)(ii)(b)
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): Licensing Officer reviewed a chart which did not contain immunization screening.
- R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Licensing Officer reviewed multiple restraint documents which did not contain reassessment dates.
- R10.4N - Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): At the time of the inspection, the licensing officer did not observe evidence of a system to ensure the person, parent or representative were advised how to make a complaint to Licensing.
- R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Licensing Officer observed unsecured cupboards containing person in care's records.
- R7.1AJ - Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Routine Inspection
2 infractions
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): Licensing Officer observed a staff file which contained an orientation checklist with four incomplete tasks. This was contrary to facility policy. Licensing Officer observed a staff file with missing performance reviews, which was also contrary to facility policy.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Licensing Officer reviewed four weeks of menus, Within these four weeks, there were five meals which included two food groups instead of three.
- R5.1C - Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Routine Inspection
0 infractions
- Monitoring
0 infractions
- Monitoring
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The tile surround in the bathroom with the bathtub is in need of repair, as there are broken tiles with sharp edges and missing caulking in some areas.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Monitoring
0 infractions
- Monitoring
9 infractions
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): 11-May-2015-It was noted that physician's orders, written agreements, and documentation were not in place for the ongoing use of restraints.
- A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
- Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73( 2 ); 75( 2 )(a)(i)(ii)(b)
- 4.3 Is documentation concerning restraints adequate?
- Observation(s): 11-May-2015-It was noted that physician's orders, written agreements, and documentation were not in place for the ongoing use of restraints.
- Record the type or nature of the restraint used in the person's care plan; 84(a)
- Record the reason for the use of restraint in the person's care plan; 84(b)
- Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
- Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
- Keep a record of employee compliance with the requirements of Division 5 (Use of Restraints) of Part 5 in the persons care plan; 84 (f)
- 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): 11-May-2015-It was noted that one resident's records did not contain evidence of TB and immunization screening, and one resident's records did not contain evidence of immunization screening.
- Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 5 )
- Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
- 10.4 Are restraint and fall prevention plans appropriate?
- Observation(s): 11-May-2015-It was noted that physician's orders, written agreements, and documentation were not in place for the ongoing use of restraints.
- Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
- Provide in the care plan a plan to address, if there is agreement to the use of restraints, the type or nature of restraint and the frequency of reassessment; 81( 3 )(a)(iii)
- 23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
- Observation(s): Refer to report.
- 25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
- Observation(s): Refer to report.
- 26 - Is a short term care plan developed on admission to guide staff in protecting and promoting the health and safety of the person in care?
- Observation(s): Refer to report.
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): 11-May-2015-It was noted that the immunization status was not evident in some Resident's records.
- Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78( 1 )(a) Director of Licensing Standards of Practice: Immunization records
- 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): 11-May-2015-It was noted that a new admission did not have a care plan in place specific to the home.
- Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b)
- Care plans must includes an oral health care plan; 81( 3 )(b)
- Develop a nutrition plan for each person in care and review the plan on a regular basis (Applies to a facility with 24 or fewer persons in care); 83( 1 )(a)( 3 )(a)
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?